Friday afternoon, an email landed in my inbox with the kind of subject line that makes me pause: “PRA Sues AMA to Make Medical Billing Codes Freely Available to the Public.” It was from Cynthia Fisher.

You guys. This is a good one.

For those of you who don’t know Cynthia - you should. A business owner and entrepreneur, she has spent her money and her winsome stubbornness on something almost nobody with her resume bothers to fight for: making American health care prices public. She founded PatientRightsAdvocate.org (PRA) in 2017 and has been the single most relentless force behind hospital and health plan price transparency rules ever since.

She’s functionally the reason any of us can look up what a hospital actually charges for anything.

The price transparency files, that Cynthia and I fought so hard to require be posted, really can be hard to access, read and interpret. That’s exactly the problem that PRA tries to solve - they post every file as an excel spreadsheet, for free, on their website. So they need to be able to publish the CPT codes and the short description associated with each code on their website in order to fulfill their mission. They also grade every hospital twice a year on its compliance with the reporting requirement. In other words, PRA is a national treasure.

So, if Cynthia is suing you, you’re bad. You’re on the wrong side of history. You’re corrupt. You’re fleecing patients and employers and everyone else who pays for sick care.

If you haven’t done much investigation into the dealings of the American Medical Association, you might be surprised to see them listed as the opposition. Aren’t they supposed to be the good guys?

Most doctors don’t even think so.

In the 1950s, the AMA represented 75 percent of American doctors. Today it’s closer to 15 percent, and even that number is generous, because the AMA’s own membership totals fold in medical students and residents who aren’t even billing anybody yet.

That kind of collapse would kill most trade associations. It didn’t kill this one, because the AMA stopped depending on its members a long time ago. Instead they’ve transformed their business model into the shenanigans outlined quite nicely in Cynthia’s lawsuit.

Cliff’s Notes on the Suit

Ok, the Cliff’s Notes version (do non-GenXers even know what that means?): every time doctors bill for anything - a checkup, a stitch, an MRI - they use a five-digit code from something called Current Procedural Terminology, or CPT. It’s not optional. Medicare requires it. Medicaid requires it. Every HIPAA-covered transaction requires it. Forty-five-plus states require it too. Skip it, get it wrong, or try to work around it, and you can eat a civil penalty of up to $50,000 per violation.

So CPT is, functionally, the law.

It’s baked into federal regulation so completely that you can’t legally bill for most health care without it, period. Which is why your ACA or employer-sponsored plan also requires it in order to pay their share of your medical bills.

And the people who wrote the first draft own the copyright. The AMA claims to own CPT outright and charges you for the privilege of looking at it - $137.89 for a physical copy of the codebook. $82.50 up front plus $18.50 per user per year if your practice, hospital system, insurer, or vendor wants electronic access, and every biller and coder in your building needs a seat. Multiply that across every hospital, insurer, and vendor in the country and you can see how the business model generates sweet, sweet cash: $296.4 million in “books and digital content” revenue for the AMA in 2025, netting $267.5 million in profit. CPT royalties alone reportedly clear $300 million a year off a coding system nobody in America is legally permitted to avoid using.

With that kind of annual cash, at least the AMA is successfully lobbying for doctors to get better pay and working conditions every year. Oh wait.

The $137.89 sticker price on a codebook is bad enough. But the scandal doesn’t stop there. Even more insidious is what AMA’s control over CPT codes does to the entire, multi-trillion dollar market that’s a fifth of the U.S. GDP. They are controlling the codes that every plan uses to pay… THEM. And you can bet your butt that they are distorting those codes in their own interest and not “solely in the interest of plan beneficiaries” - to quote the legal standard that every plan fiduciary has to follow when paying service providers with a health plan’s assets. And to be clear, when I say “their own interest,” I mean the AMA’s institutional and financial interest - not the interests of most doctors.

Hospitals and insurers have spent years slow-walking every price transparency rule anyone’s tried to force on them, and now here’s the AMA fighting in court anyone who tries to make the item descriptions on that menu public too. Hiding what something costs, apparently, wasn’t sufficient. They went after your ability to even know what the thing was called.

“No One Can Own the Law.” The AMA Apparently Missed That Memo.

On August 13th, PatientRightsAdvocate.org filed suit against the AMA in federal court in the Northern District of Illinois, and their legal theory is refreshingly blunt: you can’t copyright the law, and CPT is the law in every way that matters.

PRA leans on a doctrine the Supreme Court reaffirmed just a few years ago in Georgia v. Public.Resource.Org - when a standard gets incorporated by reference into a government regulation, the private party that wrote it doesn’t get to keep charging for it. The complaint argues CPT clears that bar in three ways: the AMA exercises what amounts to delegated lawmaking authority in maintaining it, it’s incorporated wholesale into federal regulations, and the government itself co-authored parts of it.

Beyond that, PRA argues plain old fair use - nonprofit, noncommercial re-publication of a standard incorporated into law is about as clean a fair use case as exists in copyright doctrine.

PRA also argues my personal favorite, copyright misuse, as the Ninth Circuit called it in its 1997 ruling in Practice Management Info. Corp. v. AMA. The court recognized that the AMA had misused its CPT copyright over a backroom deal it cut with the government: the AMA let the government use CPT for Medicare billing, and in exchange, the government agreed never to adopt a competing coding system. The AMA was using the government’s own regulatory muscle to guarantee itself a permanent, captive customer with zero competition, forever, at a price it alone got to set.

As a feign to that ruling, the AMA supposedly “renounced” the exclusivity clause to satisfy the court order, but by that time, the rot was so entrenched in every health care transaction in the country, that the exclusivity was already baked into everything, with or without AMA’s insistence.

The cartel takes any threats to its racket seriously.

I’ve had my own run-ins with the organized medical mafia. Years ago, working for a U.S. Senator, I recommended he co-sponsor a bill letting Certified Registered Nurse Anesthetists (CRNAs) practice at the top of their license and bill independently for standard surgical anesthesiology services they were already performing, unsupervised, every day. Here’s the arrangement the bill would have chipped away at: one anesthesiologist MD sits in a back office, doesn’t touch a single patient, and collects the professional fee for six CRNAs actually doing the work in the operating room, while those CRNAs get paid a fraction of what their labor generates.

The state anesthesiologist cartel didn’t respond with a strongly worded letter or a polite meeting request. Its leader walked up to me in a hallway, put his literal finger in my chest, and informed me that his group had a very close relationship with the Senator, had invested heavily in his career, and expected him to deliver accordingly. Just one of the many House of Cards moments in my government career.

The state’s university system, not wanting the anesthesiologists to have all the fun, later went after my job over the same bill - because I’d used what their hospital‘s CRNAs had told me about how the 6:1 nurse/MD ratio worked, to help make the public case for the legislation. Nobody disputed that the exploitation was real. What got their whining lobbyists on the phone was a Senator daring to say it out loud, with the nurses’ own quotes attached.

This is why I reach for the words I reach for when I write about them: “cartel,” “gangsters,” “mafia,” a “white-coat-religious cult” that treats its own rank-and-file as revenue units whenever that’s convenient, and treats anyone who threatens the revenue model - patients, nurses, employers, legislative staffers, competitors, entire nonprofits founded by biotech executives - as an enemy combatant to be intimidated, litigated, or fired into silence.

Same playbook, hospital edition.

If the CPT fight sounds familiar, it should. PRA is currently defending itself against a completely separate lawsuit the American Hospital Association (AHA) filed back in December, in the very same Illinois courthouse, over PRA’s plan to publish the UB-04 manual - the hospital-billing equivalent of CPT. In this case, PRA provoked the lawsuit by notifying the AHA of their intention to transparently post the information in the manual. The AHA sued first, seeking a permanent injunction and statutory damages. UB-04 licenses aren’t cheap either - the 2026 edition runs from $182 for one user up to $4,523 for 33 to 50 users, scaled like a bad SaaS pricing model for a product you’re legally required to buy.

And this isn’t the AHA’s first rodeo, losing when they try to hide prices, either. Go back to the first Trump administration’s hospital price transparency rule, which forced hospitals to post negotiated rates (you’re welcome, America). The AHA sued to block it, arguing patients didn’t have a right to know prices in advance. They got laughed out of federal district court, appealed to the D.C. Circuit, and got laughed out of there too, unanimously. Two-for-two, total defeat, and they’re still out here today running the identical playbook - sue first, delay, threaten, hope the other side runs out of money - against anyone who tries to make their billing paperwork legible to the people paying for it.

It doesn’t have to work this way

CPT isn’t the only mandatory coding system in American medicine. When your plan is billed, the bill includes the CPT code showing what service was rendered, but also why it was rendered, i.e. the diagnosis code. These diagnostic codes, known as the ICD-10-CM, are maintained by the CDC, federally mandated and baked into every claim just like CPT.

Also, completely free.

You can download the entire current-year file from a government website right now, no license, no per-seat fee, no $50,000 penalty, because the agency that maintains it treats a mandatory code as infrastructure, the same way it treats highway signage or a zip code. Weird, right?

CPT is the odd one out. It alone got claimed by a private trade group early enough, and lobbied hard enough for long enough, that it’s still treated as somebody’s intellectual property fifty-plus years later, generating $300 million a year for an organization pretending to represent doctors.

One Final Argument

When the federal government finally forced hospitals and health plans to post their prices - the hospital price transparency rule from the first Trump administration, and the Transparency in Coverage rule for insurers that came later in the first term - it didn’t ask for a vague range of potential prices. The rules required every hospital and health plan in the country to post actual negotiated rates, service by service, alongside cash price and sticker price, in free, public, machine-readable files that anyone can download right now, no account and no dime required. If you add the government’s own published Medicare fee schedules on top of that, also free and public, then every category of rate in American health care is sitting out in the open.

And virtually every line of every one of those files is identified by a CPT code, because that’s the coin of the realm.

So yeah, the government already requires every hospital and health plan in America to publish, for free, an enormous dataset entirely organized around CPT codes - including their supposedly proprietary short description of what each code stands for - codes the AMA insists that nobody like PRA may reproduce or give away without paying first.

Remember, you pay for those codes every day, even if you don’t buy access from AMA. You pay for them in the taxes that fuel almost half of all spending on health care in this country - the half that is paid for by government. The feds mandated the exact activity the AMA claims to own the exclusive right to license. Every one of those files complies with federal law by doing a version of exactly what PRA is asking a judge’s permission to do: attaching public information to a CPT code and putting it online for free.

Practically speaking, the government has already normalized the exact outcome the AMA calls catastrophic: CPT-tied information, at massive scale, free to the public, happening every day, because of these transparency rules. The AMA’s business model depends on Americans believing that free access to CPT is dangerous, even though the government’s own rules already prove otherwise, at a scale dwarfing anything PRA is proposing.

PRA and Cynthia aren’t the only ones to notice this corrupt model.

CMS’ proposed rule on 2027 physician payments, published in July, specifically asked for public comment on the “harms or challenges associated with AMA’s monopoly over CPT-4 licenses.”

Senator Bill Cassidy, chairman of the Senate committee overseeing HHS (and always eager to remind everyone, as the first sentence of every tweet or speech, that he’s a physician himself), has publicly accused the organization of abusing a “government-backed monopoly” and charging “exorbitant fees.”

In other words, litigation, congressional scrutiny, and active rulemaking are all converging on the same target at once.

Why This Costs You

You can’t audit a bill written in a language you’re not fully allowed to read, share, or build tools around, and you can’t negotiate a fair price for a medical service when the code that defines it is licensed and priced by the trade group lobbying to keep the system opaque.

Every price transparency win I’ve celebrated in this space - the machine-readable files, the posted rates, the progress toward patients and employers actually being able to make decisions based on price - depends on the vocabulary of billing being genuinely usable by the public, not just technically postable in a format nobody can parse. Right now that vocabulary is rented, from a guild that’s spent decades making sure the dictionary stays just illegible enough to protect the racket.

If you’re an employer or benefits leader, you already know the practical version of this, even if you’ve never thought about the CPT copyright. As a plan fiduciary, you have a legal duty to spend your people’s health care dollars prudently, and every vendor you hire to audit claims, every reference-based pricing plan, every TPA trying to build you a smarter network, is working with a vocabulary kept deliberately hard to use at scale.

I don’t know exactly how the lawsuit shakes out (though it seems slam-dunk to me). Courts move slowly, and both the AMA and the AHA in these legal fights with PRA have already vowed to “vigorously defend” their “intellectual property” (LOL).

You don’t hate these two groups enough.

Go read the complaint. Then go pull up your last Explanation of Benefits and get mad about it all over again, because it’s the same racket, hiding behind the white coats you trust, and - for now, anyway - the same hidden dictionary standing between you and understanding your own medical bill.

If a hospital or a physician group has ever played games with you, your practice, your legislation, or your paycheck, you already know why this lawsuit matters. Plenty of people have grumbled about this for decades. Nobody with Cynthia’s money and guileless stubbornness has ever so completely threatened the AMA’s empire. If PRA wins - and I believe they will - it’s the death knell for half a century of billing-code extortion masquerading as intellectual property. It can’t happen fast enough.

I’ve followed their work since they started. Their host, Ann Forti, has been in this fight for decades, and it shows in the questions she asks.

Halfway through our conversation, Ann mentioned that her daughter is going in for knee surgery on Monday. The estimate came back at $38,000. They are cash pay, so they asked for the other number. The other number was $6,000.

That is the health care in a nutshell, and it is why a conversation about vaccine injury turns into a conversation about hospital pricing. Because once this system hurts you, you find out fast that the billing arm runs the same playbook as the clinical arm.

Ann wanted to know why nothing is moving.

Kennedy is in. Bhattacharya is in. The wins are small and the reversals are loud.

My answer is not that the good guys sold out. My answer is that there is no functioning policy process right now, and policy is being driven by bedwetting from outside entities.

Media hits, donor dinners, a chairman threatening a nomination.

In a normal White House all of that gets aired in a room with people who can push back on it. Now it goes straight to the top with nobody there to say the polling is wrong and the science is wrong and you campaigned on this. ( I wrote about this here.)

We also got into the compensation fight for the vaccine injured. My skepticism there is about Congress, not about the people doing the work.

Don’t despair. Where everything is now is not where it will be in six months.

But no one is coming from Washington to save your health.

Listen to the episode, and then go look at what React 19 is actually doing.

The story of a nurse from Alaska is circulating around the podcast circuit these days.

McKenna West, a single mom of two, signed up to be a surrogate mother last year to make some extra money. Twenty weeks into the pregnancy, a scan found the baby had hypoplastic left heart syndrome - a serious but survivable condition requiring early surgeries but also, for most kids, an otherwise normal childhood.

The couple who’d contracted with her invoked the abortion clause in their surrogacy contract. She refused, and they sued her for a quarter million dollars. She fled to Texas, where they frown on forced abortion. The baby, Gabriel, was just born this week. The courts have ordered that he be provided the life-saving care he needs, but also that his genetic parents should have custody of him. As a result, McKenna wasn’t even allowed to hold him and provide the skin-to-skin contact that triggers a variety of critical developmental cues for him after birth.

This is just the latest, but by no means the only, controversy arising out of our country’s status as the most permissive IVF haven in the world. With President Trump and most of Congress trying to convert IVF into an entitlement, employers better buckle up.

Congress is Coming for Your Health Plan

There are a couple versions of a mandate on employers to cover IVF that have been floating around Congress for a few years now.

The Democrat-only one was actually attracting Republican support a couple years ago before the pro-life community (including, aggressively, me) raised heated opposition. That bill, sponsored by Senator Cory Booker, then and now, requires every employer plan in the country to cover IVF, with no religious exemption and no limits. It also would offer IVF to anyone, whether they’ve been diagnosed with infertility or whether they just want IVF. The bill explicitly bans “discrimination:” meaning, you’d better offer IVF to same sex couples, singles, transgender people, and senior citizens, presumably including the costs associated with commercial surrogacy, gamete purchase, etc.

The bill with bipartisan cover isn’t much better. H.R. 8119, introduced in March by Rep. Zach Nunn, a Republican from Iowa, along with Rep. Debbie Wasserman Schultz has picked up a dozen cosponsors from both parties. It requires an infertility diagnosis before coverage kicks in (nice try), but the definition of “infertility” would include seniors, people who’ve never reproduced before (maybe because they’re same sex attracted or transgender or single) - anyone whose “reproductive history” or “physical findings” render them infertile.

The bill with Republicans on it is actually worse in one way: it comes with a draconian reporting regime: every employer has to prove to the Department of Labor every year for five years that its IVF benefit is generous enough to pass muster. The Labor Secretary can order corrective action against plans deemed to be insufficient, and then fine them $100 a day and name-and-shame them publicly in a report sent to Congress.

Where Do We Even Start?

Let’s set the moral case aside for a second and look at the cost. Because employers are already saving so much money on health care these days.

Oh wait…

A single IVF cycle runs $15,000 to $30,000, and most women need more than one, and are associated with higher risk and complicated pregnancies, and more expensive pregnancies and deliveries.

Family premiums have more than quadrupled since 1999, from just under $6,000 to $27,000. Ten percent of families with job-based coverage are already costing employers over $30,000 a year. Almost half of all large employers report that they’re raising what employees pay next year just to keep up with the costs already on the books. The bills amend ERISA - the law that governs the health plans that cover two-thirds of all Americans who get their insurance on the job - and more than half the country overall. The Democrat bill covers all non-ERISA plans too. So this is a much bigger impact than the usual in-fighting in DC about health policy in the 20-million ACA market.

Remember what happened to the price of insurance when the government mandated that everyone buy it?

IVF still runs largely on cash right now, which is one of the only things keeping any lid at all on the cost. Mandate a benefit like this and you know what happens to the price of that benefit in the marketplace.

A business scared of getting on the DOL naughty list is going to overspend on IVF coverage to stay safely above suspicion, and then tighten the screws somewhere else - a higher deductible here, a stingier coinsurance rate there. Who suffers the most from this cost-shifting? Employees dealing with cancer, expensive drugs, or a kid with a genetic condition. Chemo doesn’t come with its own federal reporting mandate demanding proof your employer is paying enough for it.

What Coverage Actually Buys

Most of the “should employers cover this” debate treats it as a binary question - yes we cover it or no we don’t. But covering IVF means funding an entire industry’s standard operating practices. Most people (and politicians) haven’t looked under the hood on those.

According to CDC and IVF industry data, 90 percent of the tiny humans created by IVF die before making it to live birth. IVF has recently surpassed non-IVF abortions as the leading cause of death in children. Most fertility clinics create a batch of embryos at once rather than one or two at a time, because creating them one at a time is brutally expensive and bad for the clinic’s business model. They want you coming back to try again with your frozen embryos when the process fails the first time, without having to re-do the agonizing (and dangerous) step of hormonal manipulation, ovarian hyperstimulation and egg retrieval.

Every embryo gets eugenically screened for “fitness” (however the clinic determines it at the time) and the ones not implanted get frozen indefinitely, at your (or your employer’s) expense, or discarded. Genetic screening and sex selection are routine. After the embryos are transferred into the mother’s or the surrogate’s womb, if too many of them fail to die, then you have what’s called “selective reduction” - that’s Orwell-speak for aborting the extras to improve the odds for the one, two or three left alive.

Surrogate contracts ensure that the eugenics continue - the “terminate per contract” boilerplate provision requires the surrogate to undergo an abortion if some prenatal test along the way makes the buyers of the baby uncomfortable. Like Gabriel and his treatable heart defect.

By the way, health conditions later in life are more common in babies created under these unnatural circumstances, to the surprise of no one. Mother Nature dominates all other competitors.

And then you have third parties introduced into the IVF “benefit.” Third parties are baked into a shocking share of IVF cycles, which is an ethical and legal minefield that your company’s Benefits Committee has never been briefed on.

Motherless and Fatherless By Design

Every time a health plan pays for sperm procurement, egg procurement, or a surrogate, it’s paying to manufacture a child who will grow up permanently severed from at least one biological parent, on purpose, before he’s even conceived. Adoption exists to heal that wound after tragedy strikes a family. IVF with purchased gametes (can we drop the charade about “donors?”) creates the wound as a business model.

The research on these babies when they grow up isn’t encouraging - struggles with identity, a documented longing to know the missing half of their genetic story, higher rates of depression and a sense of being a product rather than a person.

The Egg Market

Don’t look too closely at what actually happens to the young women who sell their eggs to fund somebody else’s family.

To harvest enough eggs to make a cycle worthwhile, clinics shut down a woman’s own cycle with Lupron and synthetic hormones, then hyperstimulate her ovaries to produce ten or twenty eggs in a single month instead of the one nature intended. The known risks include Ovarian Hyperstimulation Syndrome, ovarian torsion, kidney disease, and a documented link between the estrogen doses involved and breast and uterine cancer, stroke, and blood clots.

Some women have lost their own fertility permanently from a process meant to replace somebody else’s.

And of course, when all this goes down, the egg seller isn’t the clinic’s client or the “patient” being treated. (The person paying for the cycle is the customer.) The genetic mother is merely a vendor, and a disposable one. If something goes wrong with her ovaries, her kidneys, or her fertility, either right away or years later, there’s no established system connecting that harm back to the sale, no long-term registry tracking her outcomes, and no incentive for the clinic that profited off her eggs to find out whether she’s okay.

The Sperm Market

Sperm collection sounds clinical until you say it plainly: it happens in a room down the hall from the waiting area, stocked with pornography, where a man is paid to masturbate and ejaculate into a cup. That’s true whether it’s an anonymous seller or the intended father producing his gene pool. Either way, if your plan covers the procedure, it’s covering that room and what happens there. Your company becomes complicit in all the trafficking, exploitation and other crimes pervading the porn industry.

The sperm market runs on the same eugenic sales pitch as the egg market - catalogs sorting sellers by IQ, height, athletic history, eye color, complexion, and race, sold to customers shopping for the most “desirable” genetic material available. And the vetting on the supply side has failed spectacularly and repeatedly. Indianapolis fertility doctor Donald Cline inseminated dozens of his unsuspecting patients with his own sperm through the 1970s and ‘80s - at least 50 confirmed children, by some counts closer to 100. Prosecutors discovered that what he’d done wasn’t even a crime under Indiana law at the time.

Surrogacy and the Farms

Surrogacy breaks asunder what God has joined: motherhood. Nature gives one woman all three jobs: the genetic mother whose egg gets fertilized, the birth mother who carries and bonds with the baby, and the social mother who raises the child. Surrogacy turns that into a menu - rent one role, buy another, skip a third entirely.

Once you add a surrogate mother to the mix, you’re not just buying a service, you’re buying into an industry that too often goes looking for the cheapest, most desperate wombs on the planet. Anand, a small city in Gujarat, India, became a global surrogacy hub in the 2000s precisely because poor Indian women could be recruited for a fraction of what an American surrogate charges - until India banned the practice in 2021. Ukraine’s BioTexCom, the largest surrogacy clinic in the world, got in a pickle when Russia invaded in 2022 and dozens of newborns ended up living in a bomb-shelter basement, cared for by nannies, because the foreign parents who’d ordered them couldn’t get into the country to collect them.

And the babies born through this system are subject to exactly the kind of quality control you’d expect from an industry that treats them as a product. In 2014, an Australian couple hired a Thai surrogate to carry twins, and when a prenatal test found that one of the babies had Down syndrome and a heart defect, they asked her to abort him. She refused. They took the healthy twin sister home to Australia and left the boy, whom she’d named Gammy, behind with her.

Thailand banned commercial surrogacy for foreign clients that same year.

Things are no better in America: it’s still poor women, often of color, who choose to give away their own children, or rent their wombs for the gestation of others’ children, becoming the only voice, the only smell, the only heartbeat that baby has ever known, only to be ripped away at birth, forever.

Nobody Checks Who’s Buying

Adoption in America comes with home studies, background checks, courts involved and mounds of regulatory oversight. Commercial surrogacy and gamete markets come with none of that.

In the case of the Australian couple who left Gammy behind in Thailand, David Farnell, the father, was a convicted child sex offender with three young girls as his victims. He flew home with his daughter anyway, and it took reporters digging after the Gammy story broke to find out who he actually was.

That same year, Thai authorities and Interpol investigated a young Japanese man who had fathered at least sixteen children through Thai surrogates and reportedly wanted ten to fifteen more a year. He was never charged with anything, because there was no framework in place that required anyone to ask why. Laws in every country, including ours, are woefully behind the whack-a-mole of ethical nightmares created by Big Fertility.

Legal quagmires, even for the normal couples

Now, you might be thinking about the earnest couples who try to sidestep all these ethical landmines: they create only the embryos they intend to implant, implant every one, and skip the genetic screening. That version of IVF is theoretically possible, but it’s rare, since it’s the most expensive, inefficient version and clinics have every incentive to steer people away from it.

And of course, couples break up or get divorced. There are numerous high-profile examples of celebrity couples fighting in court over the fate of their frozen embryos, with one parent wanting to keep them and one wanting to throw them away.

Then there’s the question of what happens to the embryos themselves once they’re sitting in a freezer somewhere, which is where I guess Congress wants your employer’s money sitting too, sometimes for years, sometimes for decades.

The current political frenzy over IVF traces back to a single freezer accident.

In December 2020, a patient wandered into the unsecured storage unit at a fertility clinic attached to a Mobile, Alabama hospital, reached into subzero cryogenic tanks out of curiosity, burned his hand on the cold, and dropped several embryos on the floor, destroying them instantly. Three couples whose embryos were among the ones destroyed sued the clinic. When they won because Alabama applied its definition of minor child to the embryos, political hysterics ensued. Republicans, starting with President Trump, running for his second term, competed with each other to prove who was the most committed to making IVF as accessible as a car wash - calling it pro-life, pro-family, with zero due diligence.

Whose Money, Whose Conscience

Neither bill in Congress lets an employer opt out on religious or moral grounds. Almost a quarter of the country is Catholic, and the Church teaches plainly that IVF is intrinsically immoral and that Catholics can’t fund it, cooperate with it, or look away while it happens on their payroll. Plenty of other faiths object to parts of it too. Under either bill, a Catholic hospital, a Christian college, a family business like Hobby Lobby, or a small pro-life advocacy group - all of them would be required to pay for deeply objectionable, unethical aspects of the IVF playbook, along with every employee whose premium dollars would help cover a colleague’s embryo olympics, whether they believe it’s right or not.

We already ran this exact fight over the Little Sisters of the Poor, a group of nuns who take vows of poverty and who spend their lives caring for the elderly, when the Obama administration tried to force them to pay for their non-nun employee’s birth control. It went to the Supreme Court, and the government lost. I know, because I was at the White House, holding a gun to the Trump DOJ’s head to make them settle with the sisters and the 100+ other plaintiffs.

The Employer Checklist

If you’re still determined to add IVF to your plan after all this, at least your eyes are open a little wider. But you don’t get to just check a box marked “covers IVF” and call it a day. You have to actually write the policy (I write policies for a living and it’s way more complicated than you think) which means putting an answer, in writing, next to every one of these questions:

Who gets the benefit?

• Does it cover only married couples, or anyone with a policy and a pulse?

• Does it cover same-sex couples and single people, meaning you’re paying to create a child who will grow up without a mother or a father by design?

• Does it cover transgender employees who sterilized themselves as part of their transition?

• Is there an age cutoff, or will you pay for a 60-year-old employee to become a parent using a purchased egg and a surrogate? What about the 45 year old who, statistically, is extremely unlikely to be successful, no matter how many cycles her employer pays for?

• Is there an age too young - do teenagers qualify?

• Will you cover employees who want to sell their own sperm or eggs, or serve as a surrogate, including for a family member or a colleague?

Third parties

• If you’re buying eggs: are you paying for the hormone injections, the hyperstimulation, and the retrieval? What happens if she develops Ovarian Hyperstimulation Syndrome, or loses her own fertility as a result, immediately or years later? Who decides that the harm is connected to the egg retrieval, and who pays for it then? Does the plan still pay if none of her eggs turn out to be usable?

• If you’re buying sperm: are you paying for the room and the materials facilitating the sample collection?

• If you’re covering a surrogate: what happens if she miscarries? Do you pay for a second surrogate? A third? Is there a cap on how many surrogacy arrangements you’ll fund per employee per year? Will you cover a surrogate based overseas, and if so, how will you verify her medical bills, her age, or whether she was recruited, coerced, or trafficked into a surrogacy farm? If you won’t cover the surrogate’s own costs, will you still cover everything else if your employee chooses a foreign surrogate from a farm anyway?

Embryos

• Will you pay for genetic screening of embryos? Just viability, or also disease risk, the parents’ preferred sex, and other traits?

• If none of the embryos created are graded as “fit,” do you still pay for a transfer if the couple wants to try anyway?

• How many embryos will you pay to create in a single cycle?

• How many will you pay to transfer into the womb at once - all of them? Two? Three?

• If too many implant, will you pay for the abortion, I mean, “selective reduction” that follows? How many implanted embryos count as an acceptable number to let survive?

• Will you pay to freeze the embryos that aren’t used? For how long? What happens to that bill after five years? Ten?

Procedure coverage

• How many cycles will you cover per employee, and is there a dollar cap per cycle or per lifetime?

• Does the benefit cover egg freezing for an employee who just wants to delay having kids, with no infertility diagnosis at all?

Conscientious objectors

• What’s your plan for employees with a sincerely held religious objection to funding a plan that covers IVF?

• Will you offer a separate plan option that excludes IVF, or are you prepared to defend this one in court?

Not trying to be judgey. I’ve been there.

I got the “infertile” diagnosis myself more than a decade ago, off one ultrasound cycle, from a doctor I never thought to question. I didn’t do a single savvy thing with that information. I didn’t investigate root causes, didn’t fix my hormones, didn’t find some enlightened doctor who bothered to ask why my body wasn’t working. I believed her, grieved it, and my husband and I adopted.

Years later, studying to become a naturopath, I learned that infertility was a symptom, not the disease, very often reversible rather than a life sentence. That ought to give employers a better option when it comes to helping their workers have the babies they so desperately want. The real gap in coverage is for functional, root cause healing. Infertility is the tip of the iceberg of metabolic and other bodily meltdown that will translate to misery and high employer costs later. But health coaching, functional lab tests, couples counseling, homeopathy, and holistic sleep specialists - the type of services that can help reverse the metabolic disorder, inflammation, and hormonal chaos behind much infertility - are rarely covered by your employee health plan.

Beyond the whole-system approach, more targeted, restorative reproductive medicine is a burgeoning field that has finally started to go mainstream. When coded properly, it’s usually covered by health plans, but it’s important for employers to check on that, as it’s been a gap in the past.

None of this requires an ERISA mandate, a federal reporting scheme, or a conscience fight.

Back to the Question

So, should your health plan cover IVF? Should any employer health plan cover IVF?

Well, sure. If your company is down for doing a deal with the devil: a business with a 93 percent loss rate, routine eugenics, intentional separation of children from their biological parents, and contracts that treat a baby’s heart defect as grounds for forced abortions. Her body, her choice, amiright?

Baby Gabriel is still in some NICU, separated from the only mother he’s ever known, waiting on the parents who tried to force her to kill him to oversee the medical care for him that a court had to order over their objections. Unless we want this story at industrial scale, employers should opt way out of this one and fight any legislation being recklessly pushed by uninformed politicians - who clearly need better staff - with everything they have.

The national atheist group was testifying against me that day. Well, against my cause. Which, I guess, bodes well for me in the heavenly brownie points ledger.

I was at the witness table at a state legislative hearing in one of those hyper-blue states it’s easy to complain about. The chairman of the committee had introduced a bill, written by the atheists, that, if passed, would impose an ungodly (and unconstitutional) amount of requirements on health care sharing ministries operating in the state.

The atheists were testifying virtually - on the jumbo screen to my left. I was there in person, because I have learned that when a fight is on, something very important can give you an advantage as your electromagnetic field overlaps with someone else’s. Human connection matters. (Maybe someone could let Fauci’s diary in on that).

The national atheist group was going around to a variety of blue states and finding legislators with hostile records on religious liberty, and getting them to rubber stamp their “model” bill persecuting Christians who come together to share medical bills.

One problem with the bill in this particular state: it had laughably over-the-top provisions, like requiring health care sharing members to be finger-printed by the state. One other problem for the atheists: the bill sponsor didn’t even realize what was in his bill. He got flummoxed when I pointed out the fingerprinting. Denied it. Had to correct himself when we pointed out the chapter and verse. Whoops!

How to properly staff a committee chairman is a class I’ve actually taught to graduate students, but I’ll leave that for another day. The point is, the atheists lost that battle, the bill stalled out (for now), and we lived to fight another day.

I bring this up not to toot my own horn - there were plenty of less awesome hearings during the six years I ran this trade group - but because it’s a pretty good encapsulation of where health care sharing ministries sit in this country right now: growing fast, confusing regulators and legislators, occasionally infuriating them, occasionally deserving to infuriate them, and almost never explained well to the people actually trying to decide whether to join one.

Ask me how I know

I’ve been inside this fight from more angles than almost anyone alive.

I worked on health care sharing policy from inside the government - both in the Senate and the White House - back when most of official Washington couldn’t have told you the difference between a health care sharing ministry and a health savings account. Then I left government and ran the trade association for the handful of ACA-recognized, nonprofit religious ministries for six years. That meant testifying, lobbying, and even getting deposed, in front of the continuum of regulators - from hostile to confused to friendly - in dozens of state capitals and DC.

I have patiently explained the concept of “this is not insurance, and here is why that’s legal” more times than I’ve explained anything else in my career (including why ending secret health care prices doesn’t drive up health care prices, which I thought had maxed out my tolerance for repetition).

Herding cats doesn’t begin to cover it.

Some of these ministries have deeply held, decades-old convictions about how they operate and would rather close their doors than change a comma. Others want to move fast and disrupt the health care status quo. My job was to get all of them rowing in the same direction toward the same regulators without anyone getting walked down the plank. Mostly, I succeeded. Sometimes I did not, and I have the scars - and the rolodex full of lawyers - to prove it.

Full disclosure, I currently sit on the board of one of the largest brands in the health care sharing world. So you should know, going in, that I have skin in this game, and that I like the model enough to put my own name on it. That also means that this isn’t a takedown piece. But it is the truth, the way I’d explain it to a friend who just texted me “hey is one of these things legit or is it a scam?” - which, incidentally, is a text I get about once a month.

So, What Actually Is a Health Care Sharing Ministry?

Strip away the logos and the theology, and here’s the mechanism: a health care sharing ministry is a nonprofit religious charity where members - bound by a shared set of faith convictions - agree to help pay each other’s medical bills.

Not “insure.” Help pay.

Each month, you send a fixed monthly amount to another member with a medical bill. For big bills, multiple members contribute. The ministry makes the match and facilitates the transfer. This isn’t a premium. There’s no insurance contract, because there’s no insurance company. When you get sick or hurt, you (or your health care provider) submit the bill, the ministry checks it against a public set of sharing guidelines that the membership itself agreed to in advance, and then the ministry facilitates moving money from enough other members to assist with that need.

Nobody is legally guaranteeing they’ll pay you a dime. This is the whole design: you are voluntarily, prayerfully, financially showing up for people you’ve never met, and trusting that they’ll show up for you.

Some of these communities are tiny - a few hundred people in a closed Anabaptist or Mennonite fellowship who’ve been doing this for a century. Others are bigger - nationwide, open to any believer who adopts the statement of faith, with memberships in the hundreds of thousands. In between, you’ve got dozens of others of every size and flavor. Roughly a hundred organizations nationwide - mostly the tiny variety - currently meet the federal government’s technical definition of a health care sharing ministry. Only a handful of the big national ones account for the overwhelming majority of actual members.

Congress weighed in

The Affordable Care Act (ACA) recognizes health care sharing ministries who meet a (limited) set of good-actor criteria and members of such ministries get a get-out-tax-jail-free card. To get that credential, an organization has to have been sharing bills a long time (since 1999), have a religious or ethical basis for membership, independent audits, and so forth. All of this was Congress’ way of saying “no, you can’t just spin one of these up next week and declare yourself exempt from insurance law.”

Once certified, members of that ministry are exempt from the ACA’s individual mandate (a largely academic point now that Congress zeroed out the mandate penalty for everyone in 2019). It also means that the ministries aren’t insurance and don’t have to comply with the rest of the law telling insurers what to do - what they have to cover, what it has to cost, making healthy people pay the same as sick people at the starting line, and so forth.

That last part is the whole ballgame, legally speaking.

It’s also exactly why some state regulators - hi, Colorado - keep circling back with new reporting requirements, because “not insurance” makes them nervous, even when it’s Congress, not a loophole, that put it there.

Can This Actually Get Me Out of My ACA Premium?

So while nobody needs an exemption from the ACA anymore, what you’re still trying to escape these days is the price on that monthly premium bill, which, if you’re anywhere near the upper end of the subsidy cliff, just got a lot uglier now that the pandemic-era enhanced subsidies expired at the end of 2025. A lot of middle-class families who got used to a manageable premium are staring at a bill two or three times higher this year, for a plan they barely use because of good health, high deductibles or narrow networks.

Health care sharing ministry memberships generally cost between 50-70 percent of what insurance costs. If this model might be a good fit for you (more on that later), it is WELL worth serious consideration.

Some come for the cost and stay for the faith. Others come for the faith - if you’re a regular reader, you know that I think insurance carriers are largely doing the devil’s work, and it shows. Having a solution for expensive medical bills without feeding the bureaucratic, profiteering United, Cigna or Blue Cross Borg feels like a gift of the Holy Spirit.

Here’s the honest version of what a ministry can and can’t do for you.

It can, for many families and individuals with genuine religious conviction, meaningfully lower your monthly outlay to manage your medical bills - especially compared to an unsubsidized ACA plan - sometimes dramatically. It can connect you to a community that will actually pray for you and check in on you when you’re sick, which no insurance company is known for.

One of the ministries sends care packages to families who experienced a miscarriage. Another one shows up in person when a member passes away, to personally hand a donation check to the family to help with funeral costs. Most ministries have extra charity funds outside their regular sharing programs to help members with hardships of various kinds. That community feels quite different from insurance.

Still, these are charities, and as such, they don’t promise you anything. Not legally, not contractually. There is no regulator you can appeal to if the ministry decides your bill isn’t shareable under its guidelines. There’s typically a waiting period, or an outright exclusion, for pre-existing conditions - every reputable ministry discloses this up front, but it will absolutely matter to you if you have one. You are agreeing, in writing, to certain lifestyle commitments consistent with the ministry’s faith statement, and yes, they can and do check if you happen to accidentally slice your finger off when sacrificing a goat (looking at you, my atheist-lobbyist friends!). And when your bill comes in super high for that cancer treatment, you are relying entirely on the ministry’s governance, transparency, the cash position of its members, and its integrity - not on state guaranty funds or federal law.

This may sound risky to those outside the fold.

And depending on just how far outside the fold you go, it very well could be risky. Christians in community are used to relying on each other, though - that’s not a foreign concept for us. When a family in my Catholic circle has a baby, they can take it to the bank that there will be five casseroles that show up on their doorstep within a week. Churches enter into million-dollar construction projects on the reliability of the faithful’s pledges in a capital campaign.

Christians also know that you don’t send your tithe by carrier pigeon to a PO box owned by some storefront “church” that hung a shingle in the strip mall down the street last Saturday. We do our due diligence. We ask around, we check the pastor’s credentials, we check charitable records, we google for scandals, we donate through a secure portal that we’ve used before, dedicated solely to churches.

Which brings us to the actual point of this article.

The Four Kinds of Sharing (Not All Involve Jesus)

After twenty-some years of watching this space from all angles, I’ve come to sort health care sharing organizations into one of four buckets.

Jesus in Action

This category is the real deal, doing exactly what they say on the label. A church, an association of churches, or a nonprofit with the IRS paperwork to prove it. Religiously grounded, and not as a marketing veneer. Actual Christians that you know in real life who have experience as members. Transparent sharing guidelines, published where anyone can read them before they join. HHS-certified, meaning they’ve been continuously operating since the last century - not a shell that filed paperwork last spring. Audited financials that are available to anyone who asks, because they’ve got nothing to hide.

Increasingly, the best of these have also gone through independent, voluntary accreditation - a process launched a few years back (with my help, full disclosure) specifically because the good actors in this space got tired of being lumped in with the bad ones, and wanted a way to prove their integrity. That accreditation digs into governance, conflicts of interest, related-party transactions, how fast they actually share bills, what percentage of your dollar goes to overhead versus actual member need. It’s not required by law. The ministries that volunteer for that level of scrutiny are telling you something important about who they are.

This is obviously the category of ministries where I’d point my own family.

Jesus-Adjacent

This bucket includes two sub-buckets, both of which are organizations that appear - to me, anyway - to be good organizations trying to do things right. First are the HHS-certified, honest-to-goodness nonprofit ministries. Real faith community, real sharing, nobody’s running off with your money. Probably.

The reason for the “probably” is that they haven’t sought outside accreditation. It might be fine - nothing illegal, nothing fraudulent — just less independent tire-kickers checking the boxes. Maybe they’re a newer organization and therefore don’t have the HHS certification (HHS stopped certifying a while ago). Maybe they’re small and accreditation is expensive (it is, but not that expensive for an organization that exists to help with medical bills - the most expensive bills on the planet).

The other sub-bucket of Jesus-adjacent organizations is for those organized around ethical principles rather than religious beliefs. In other words, they take all comers. They’re non-profit orgs that are in this game for a noble purpose - to disrupt health insurance with a radical, non-insurance model - but not a Biblical purpose (to operationalize Acts 2:45, for instance). There are three organizations in this bucket that I’m aware of that are reputable and do a good job, and that are run by good humans who care. But still, they’re relatively new, and as far as I know, don’t have any independent third parties scrutinizing their operations. Also, without the religious exercise defense, they tend to have a thinner legal/constitutional shield when hostile regulators come at them. As such, they don’t operate in all fifty states and some members in unfriendly states could find themselves out of luck if their healthshare gets on the wrong insurance commissioner’s radar. But to be clear, I absolutely am pulling for them and wish them success!

Jesus, Inc.

Health care sharing organizations are generally not-for-profit. But a few try to turn this model into a money-making machine, either directly or indirectly, and they make everyone else look bad. Either they’re legally not-for-profit organizations but they spin off for-profit entities as vendors serving the ministry, which happen to be owned by friends and family, or they’re just for-profit entities from the get-go. I far prefer the latter - if you’re going to be a for-profit, Christian company, go ahead. (After all, my own businesses are for-profit, Christian companies.)

When the organization itself is technically not-for-profit, but the profit motive is pursued through for-profit vendors enriching the founders or their families, it can be the hardest kind of risk for an outsider to spot. The 501(c)(3) letter looks the same. The HHS certification looks the same. The prayer newsletter looks the same. The self-dealing is buried in a related-party footnote most members will never read, if it’s disclosed at all.

The other sub-bucket - sharing organizations that are openly for-profit companies - has many of the same risks that any for-profit endeavor in health care can - misaligned incentives. Equating saving money with denying or delaying care, choosing vendors that pay them better rather than serve their members better, cutting corners with staff ratios or AI bots, and on and on.

I feel strongly that, for a cooperative sharing model to work best, it needs to be a nonprofit community of people who share the same goals: helping each other get the best care at the lowest cost, not enriching owners or founders. The IRS has a robust set of rules around governance and conflicts of interest for tax-exempt organizations, and that framework, when followed scrupulously, helps protect the model.

Jesus Front Groups

And then there’s outright fraud.

These aren’t sharing organizations at all. They’re for-profit insurance-adjacent schemes that borrow “sharing ministry” language purely to dodge state insurance regulation, with zero intention of running an actual faith community or honoring sharing guidelines. Health care sharing ministries get unfairly criticized for being “unregulated.” That’s not true - they’re regulated by every state’s Attorney General, who is responsible for making sure charitable organizations don’t lie, cheat or steal from the citizenry. Fraud is illegal everywhere and when it happens, the AG can and should get involved.

The worst case of this involved a front group that reportedly siphoned 84 cents of every member dollar toward a for-profit venture owned by its founding family, while routinely denying the medical bills it was supposedly there to help pay. Eventually, a dozen or so state AGs caught up with the scheme. The subsequent bankruptcy left tens of thousands of members on the hook with medical debt. This is what regulators picture every single time a real ministry walks into a hearing room. It’s exhausting. It’s also, I’ll admit through gritted teeth, quite reasonable of them to want to prevent.

So How Do You Tell the Difference?

You don’t need a law degree. You need to ask specific questions and actually demand the paperwork, the same way I taught state regulators to ask them.

☐ Can you produce an HHS certification letter? This is an older credential, but at the very least it confirms the organization has actually been around for a quarter-century, and meets the most basic criteria laid out in the ACA (not-for-profit, independent audits, etc).

☐ Have you received, or are you actively pursuing, independent accreditation? Ask which accreditation body, look at their website and the standards they use. An organization that’s opened its books to outside scrutiny is telling on itself in the best way.

☐ Do you have an IRS (c)(3) determination letter and, if applicable, are you filing Form 990s? Every legitimate ministry above a certain size has one and you can find the info at the IRS charitable organization search tool. One of the biggest ministries, though, is actually an association of churches not required to file 990s, so you won’t find the form for them.

☐ Are your sharing guidelines public, in plain English, before I pay you a dime? Not a sales call. Not a PDF that materializes after you’ve enrolled. The entire program is posted publicly in writing, for everyone to see.

☐ What happens with my pre-existing condition, specifically? Get any waiting period, exclusion or dollar limit in writing. If you aren’t sure about whether bills arising from your pre-existing condition are shareable, be sure to ask specifically about that. The ministry may need to look at your health records to sort out exactly what will be excluded and what will be shareable, so give them time to do this. You want the answer to be correct and for your future to be predictable before you make any decision.

☐ What percentage of my monthly share actually goes to paying member medical needs, versus overhead? A real ministry will know this number cold and tell you without blinking. Bigger ministries will have numbers like 70-80 percent or higher. Smaller ministries can still be doing a great job at 55 percent or higher - their lower number of sharing requests compared to their payroll expenses can skew the ratio - as long as the other good-actor boxes are checked for them.

☐ Are you a member of the Alliance of Health Care Sharing Ministries? This is the trade group I mentioned earlier. Their members are the handful of large, nationwide ministries that are the most reputable, religiously based, and HHS-certified. They are the standard-setters and are generally the group advocating for the freedom of all health care sharing organizations to operate, interfacing with governments at the state and federal level. The Alliance is pretty insistent that their members behave, so membership is a good sign.

What are the Blaring Red Flags?

• Anyone on the phone describing it as “just like insurance, but cheaper.”

• Anyone who says it’s “ACA-compliant” without producing an HHS certification letter.

• No published sharing guidelines you can find on your own before you call.

• A broker coming on strong like a used car salesman and deflecting when you ask about insurance options so you can weigh whether insurance or a healthshare is best for you.

• “Ministry” language with no religious affirmation or lifestyle commitment required at all - that’s a tell that the “ministry” part is decorative.

• And this one’s free - if it feels like buying a timeshare more than joining a church, run.

Assuming the HealthShare is Reputable, Why Wouldn’t Everyone Join?

Health care sharing is an amazing and affordable solution - IF:

• You’re generally healthy without significant pre-existing conditions requiring treatment or medications that you can’t afford to pay cash for. (Looking at you, MAHA Moms!) Most sharing organizations don’t share in bills arising from conditions you have when you join. That includes pregnancy, FYI. They are designed to help you with illness or injury that arises after you join. Some ministries have health coaching programs that they encourage or require you to participate in if you enter the community with certain conditions that can be reversed with lifestyle interventions.

• You take ongoing medications, but they’re generic. Most sharing programs don’t share in long-term medications, so if you’re on BP or cholesterol meds, an asthma inhaler, an SSRI or hormone replacement therapy, be sure that you know the cash price and can afford it. If you or someone in your family needs a $9,000/mo drug like Skyrizi for psoriasis, this model is not for you.

• You have conscience objections to what most insurance plans cover - especially in states that require insurance plans to cover (and enrollees’ premium dollars to subsidize) killing unborn babies and trans-ing kids. Religious health care sharing ministries are not going to spend your money on immoral stuff. (I mean, except for price-gouging hospitals pretending to be charities. There’s no escape from that degeneracy.)

• You are a committed Christian or, if the sharing organization isn’t religious, you are truly committed to the non-insurance model. Most ministries require more paperwork or bill negotiation, or dialogue with providers around cash pay. That kind of extra effort means that you have to really believe in what you’re doing. But if you do, you’ve found your people - the ministry community allows opportunities for prayer, socializing and additional service between members.

I Want to Offer This for My Employees!

Everything above was written for an individual or a family shopping for themselves.

Alternatively, if you’re an employer looking to facilitate or subsidize access to ministry memberships for your team, health care sharing can be a great fit. But there are lots of caveats and compliance requirements, as every HR leader is all too familiar with. The most important advice I can give you is to work with an independent benefits advisor who does not have a financial relationship or other conflict of interest with the sharing organization, beyond any transparently-disclosed commissions. I’ve seen churches get caught up in schemes where their spending on an insurance offering and their health care sharing offering were co-mingled inappropriately into one confusing, noncompliant benefit created by a legally unsophisticated sharing organization trying to do too much. This can attract unwanted attention from a state insurance commissioner, or a lawsuit by a disgruntled employee.

Being Different is Worth It

I’ve been deposed by state attorneys general as a plaintiff defending the constitutional rights of health care sharing ministries. I’ve been grilled by insurance commissioners, Hill staffers for the atheist caucus (yeah, there’s a caucus for that), and hostile producers from the John Oliver Show. The reason why the enemies of the faith keep coming for health care sharing ministries is because they are truly subversive to the insurance Leviathan.

Some people truly need an insurance policy. But not everyone.

There are at least a million Americans who are members of a health care sharing ministry today. I’ve heard hundreds of their testimonies, from a variety of different ministries, describing how their faith community came through for them when they were scared, vulnerable, and suffering.

Many of us are working hard to treat our bodies right, stave off chronic illness, and remain squarely outside the conventional medical system almost all the time - but we’d like the peace of mind that, when we have emergencies, there’s a community holding a safety net underneath us. For us - health care sharing is a fantastic fit.

So yeah, I believe in this model.

Not blindly - there have been Bucket Four baddies scamming innocent people. But I’ve also watched truck drivers, small business owners, and young families who can’t afford a $2,200/month ACA premium find something beautiful in health care sharing that no insurance company has ever once offered them: a community that actually shows up, prays and pays.

Do your homework. Ask the hard questions. And if and when you find your match, stick it to Big Insurance in the best way possible - by opting out.

Kevin and Donna are both pharmacists.

Donna’s focus is deprescribing: getting people off medications that are hurting them more than helping. Kevin digs deeper on the digital health and systems side of things. They both see the consequences of good and bad health policy first hand, day in and day out. Perfect setting for a chat.

We started with some background. How I began my career as an infectious disease epidemiologist with dreams of going to Africa, wearing a space suit, and quarantining towns. How, when I got to South Sudan, I figured out I didn’t have the diplomacy skills for negotiating with warlords. And how when I came home, Capitol Hill sucked me in. All of it led me, somehow, to the White House. When I finally got out of DC, I couldn’t bear going out to shill for industry, so I decided to use my health care chops to build health plans so I could sleep at night.

Then we got into the good stuff I’ve learned through it all:

→ Why your fee-for-service doctor needs their patient panel to be sick
→ What you find underneath a health plan once you unbundle it and the conflicts of interest are finally visible
→ Why our health plans run on one nurse who knows your name instead of a call center
→ And why they incorporate direct primary care which is expensive, but not as expensive as unmanaged chronic illness.

And the most important thing, even if you don’t care about health policy at all:

Washington isn’t coming to save you. Neither is your insurance plan. And especially not the white coats at the hospital.

Nobody cares about your health more than you. Nobody is more of an expert in your body than you are. YOU are your primary care provider.

We break it all down in this episode.

Watch Here

I say “my” because, I was, in fact, one of them. Two years in the convent, a decade before I ever dreamed I’d end up as their benefits advisor.

As regular readers may recall, in the middle of my Senate career, I got sick of government and wanted to escape.

I’d recently become Catholic, fell in love with the Church and figured that meant I should probably become a nun. As one does.

In reality, I was just burned out by a stressful career and thought joining a convent would be like going on retreat for the rest of my life. Which still sounds awesome.

It turns out that a need for a vacation, being impressed with Catholic theology, and fatigue with the whole hair/makeup/heels ritual did not actually mean God intended for me to marry Him. I mean, who could blame Him?

So I washed out. The breakup was entirely amicable.

They literally sang me down the aisle, Sound-of-Music style.

What I never managed to escape was their health plan.

Back then, when I was still in the convent, it was a garbage fully-insured Blue Cross plan with a $4,000 deductible. Not one of the sisters (myself included) had a penny of income, of course.

They never will. (That’s kinda the point of the vow of poverty thing).

Shortly after I left, like Job, my life was restored to me - my parents gave me back my dogs, my sister gave back my cats, we kicked the renters out of my Capitol Hill house, and I returned to my career in health policy in the Senate like nothing had happened. That’s when the sisters started asking me for help with their health plan.

Couldn’t I do something about the constant rate hikes?

I called up the BCBS lobbyist I knew and tried shaming. It didn’t work, unsurprisingly I guess.

I went back to my life, periodically trying to help the sisters with ideas over the next few years. Then, in the White House, I met a group called Health Rosetta - a tribe of insurgent benefits advisors - and learned that you could do radical things with health plans.

What I didn’t know then was that it would lead me exactly where I am today.

[Now, all you Health Rosetta readers out there, you know what’s coming next - the formula for saving a health plan - so this won’t be any big news to you!]

We Fired Everybody

A year or so after that initial meeting, I left the White House and called up the sisters and said “I think I now know how to help you guys.”

And so began the inevitable argument with their insurance broker at the time, a nice man who sold status quo garbage for a living, who refused to obtain their data so we could do any analysis on their fully-insured plan. (“Fully-insured” = garbage, overpriced, carrier-owned plan. “Self-funded” = employer-owned plan that may also be garbage if run by a carrier, but can also be awesome, depending on how you run it).

No matter.

We fired Blue Cross. We fired Express Scripts - their rapey/pillagy pharmacy benefits manager, the largest in the country.

We went all in on the most radical plan design - no network.

The plan’s “allowable amount” - that’s the starting point for negotiations for what the plan pays docs and hospitals - was set to 125 percent of Medicare rates. Readers might recall from previous posts that Medicare rates are used as a proxy for wholesale cost of care, and that a 50-80 percent markup above that rate is generally considered a “good” rate on a commercial plan. If you can get health care providers to accept that rate most of the time, then you can still save a ton even with the few times that a provider tells you to pound sand and you have to pay more. So, 125 percent is aggressive.

But my thinking was: start at a really good price and threaten anyone who doesn’t accept that rate with a long time in purgatory for having screwed over nuns.

Gob-Smacking

We just started the eighth year since ditching the Blues. The results are truly gob-smacking.

In case you don’t believe your eyes, yes, after slashing spend by 32 percent in year 1, we have beaten the 2018-2019 fully-insured Blue Cross rates every year in terms of absolute, non-inflation-adjusted dollars - and that’s with increasing enrollment from 108 sisters when we started to about 120 now.

In other words - almost a decade later, with a dramatic increase in overall inflation as well as health care inflation - the sisters are still paying WAY less today than they were with Blue. The dollar figure associated with these savings, in absolute, non-adjusted dollars, is $1,272,504 less than what they paid for their garbage plan in the 2018-2019 plan year - if Blue had never raised their rates since 2018.

But of course, Blue did raise their rates each year, and how.

So, to estimate a savings amount based on some assumptions of what Blue might have raised the rates to be, let’s assume a ridiculously unrealistic health care inflation rate of, say, five percent each year. That’s ridiculous because the actual annual trend has been closer to 10 percent each year.

Assuming only that five percent, the sisters have saved $2,347,379 since leaving Big Blue.

But we can do better than just make conservative trend assumptions. We can actually ask Blue to tell us what they’d charge the sisters by requesting a quoted premium price if the sisters were to come back to the Blue plantation - which we did a few months ago. The quote came back at almost three times what the sisters are currently spending.

But wait, it gets better! Remember that $4,000 deductible on the old Blue plan that the sisters would have to raise and pay for a sister, before their coverage even kicks in at all?

Their new, un-Blue plan was designed to have no member costs. Zero. Meaning, no deductibles. No copays. No coinsurance. Since the sisters have no personal income and the religious order was going to have to raise money for “member” costs as well as “plan” costs regardless, we just eliminated all the member costs.

It Wasn’t Easy

This hasn’t been a cake-walk.

Regular readers will know that this group was both my first - and my last - reference-based pricing plan (RBP), full stop. RBP or no-network plans can save a ton of money. But when a provider doesn’t accept the plan’s 125 percent of Medicare rate, the patient gets a balance bill. That problem has real consequences - nuns being sent to collections (apparently, eternal damnation is not a deterrent to every health care provider. But we already knew that, didn’t we?). However, it is also easy to solve when you have a competent vendor that negotiates with the aggrieved doctors and hospitals. Which we have now.

That’s the easier problem.

The harder problem to solve is the access friction with a no-network plan, which can be agonizing. Front desk people at the doctor or hospital insist that they don’t take the plan (because there’s no network logo on the ID card) and refuse to give the sisters an appointment. It has taken years of adjustments to the navigation and negotiation workflow to get things just right so as to minimize delays in care.

We’ve had our horror stories.

I will say that only this year - for the first time in seven years - have we landed on a navigation partner who can actually pay cash upfront and effectively overcome this problem once and for all. I am so grateful for this partnership.

Nothing but cash-pay has ever worked for us on the access friction question.

Some advisors hack this problem by doing direct contracts with a bunch of providers in their local community, essentially creating a custom network. But the sisters are spread all over the country in little groups of 3-8 - not enough volume to lure a hospital into doing contracts with us.

Cash is king! Cash is the future! All hail cash!

But Don’t They All Qualify for Medicaid or Charity Care?

As I mentioned, none of the sisters has any personal income, which means they would all qualify for Medicaid - the government safety net insurance program for poor people. But the sisters prefer not to use government programs most of the time. Although we do occasionally request charity care from nonprofit hospitals.

Scheduling staff see that the sister has a plan ID card and think, not knowing anything about self-funded plans, that the sisters have some deep-pocketed carrier insuring them. It takes significant effort to explain that, no, the sisters fund their own plan (hence, “self-funded”) through charitable fundraising, and so they still qualify for most hospital charity programs.

The ACA requires all tax-exempt, “not-for-profit” hospitals (LOL) to have a financial assistance program to offer poor patients. It requires nothing about how big or generous that program has to be, who is eligible, or any other rules. We generally steer the sisters far away from hospitals for all the reasons I’ve written about before. But when emergency or inpatient hospital care is unavoidable, we offer cash first, a single-person contract for that sister second, and if we can’t get fair rates either way, then we will often apply for the hospital’s charity care. Hospitals are free to turn down the sisters, but they usually don’t, at least in cases when the care has already happened. This is because you usually can’t even apply for the financial assistance program until you’ve already received service and now have a bill in hand.

Sometimes you can apply earlier in the process - but only once you’re already a patient, meaning, at least after you’ve been scheduled for care. But as I mentioned earlier - the sisters often can’t get in the door to get scheduled without paying cash upfront or negotiating a single-member contract. Once you’ve done one of those things, the hospital isn’t going to give you charity - they got their money.

Even if they do accept you into the charity, usually the program only covers the member’s cost, not the plan cost. But recall that the sisters don’t have member costs. So then the hospital will say, “but you have no costs, and your plan is covering everything, so why do you need charity?” It’s very hard to make them understand that the plan itself is just the religious order, that has no income just like the sister has no income, and the plan has to raise charitable donations to cover the sister’s bill. It just doesn’t fit the use case these hospitals expect.

Hospital Charity Programs Can Work for Your Employer Plan Too

We apply for the programs on behalf of the sisters ourselves, and they are easy applications because there is literally no income, no tax returns, nothing. Your workforce might be more complicated. But that doesn’t mean you don’t have lower-income workers and dependents on your plan who would qualify. There are vendor partners out there who can help you design your plan to actually optimize the use of hospital financial assistance programs for your lower-income plan enrollees. And if you design the benefits with this in mind, you could save your enrollees a boatload. You can save the plan a ton as well.

If the Plan Doesn’t Have Money Except Donations, What Happens When the Bill Is Insanely High?

Good question - the sisters don’t have deep pockets.

When they get hit with a surprise multi-thousand dollar bill for one dose of a medicine, they have to take deep breaths, just like you or I would. Fortunately, we’ve planned for this situation.

Once claims on any one sister exceed the plan’s level of risk tolerance - their stop-loss reinsurance coverage kicks in. They pay a small - under $100 a month premium per sister - for this risk mitigation in the case of per-member claims that exceed $40,000 in a given year.

Even with this layer of fixed cost baked in, their annual spend has been dramatically improved compared to when they were “fully-insured” with Blue.

What Does All This Mean for Me?

Most of our clients don’t want to assume cost control measures quite as aggressive as the sisters do: no network, very low payment rate compared to Medicare, paying cash upfront for almost everything, use of charity programs when appropriate.

Your plan probably uses a network. And network plans - even when the carrier itself has been fired as the plan administrator, and the plan is just renting the carrier’s network - have had a wildly volatile few years recently. With the infusion of AI into exam rooms listening to your conversation with your doctor for opportunities to gouge you more, and with anti-competitive (I would argue, illegal) network contracts (with both employers and with providers), even the most aggressive employers are rarely enjoying plan performance as sweet as my nuns’.

But the nuns’ experience is worth examining anyway, because it shows what’s possible in the cash-pay health care economy of the future.

That future is increasingly being built, one plan at a time, partnering with next-gen vendor partners who are able to bypass networks or leave them off altogether. Innovative plan designs that don’t yet use cash can still obtain dramatic cost reductions compared to status quo plan designs.

It is well worth you calling up HR at your company and asking:

• Have we considered firing our carrier and just renting a network?

• Does our plan have a solution for paying cash to save money?

• Have we fired our PBM in favor of an indie, less conflicted version?

• Are we making use of hospital financial assistance programs for our lower-income colleagues?

• Do we have access to our claims data so that we know what’s driving our costs?

Most HR directors are by nature extremely risk-averse. They don’t want you to have a bad experience with the health plan that you rely on. They’re overworked already and look quite askance at a big change management project that a new plan transition can require. But if they start getting asked these questions by you and your colleagues - along with your reassurance that you would welcome and encourage these kinds of reforms to your company’s plan, they’re far more likely to entertain crazy ideas!

And every bit counts.

Any step you can take - even a simple health reimbursement arrangement program that allows workers to pay cash and get lower prices - represents progress toward disrupting the corrupt status quo that we spend so much time excoriating in this space.

Trust me when I tell you: no one is coming from government to save your company’s health plan.

The revolution starts with you and your colleagues, refusing to be fleeced by big carriers eating away your wages and your company’s growth year after year.

Be the change!

(And of course, if you need help, that’s what I do).

If the cost of health care is crushing you, this one’s for you. Send it to your HR director. And your CEO. Then leave a comment below, let me know what they said.

It was my first year on the Domestic Policy Council (DPC), and we ran the smoothest, most harmonious policy process of my entire career.

Every single agency with a stake in the outcome - and there were an absurd number of them - agreed. Completely. Unanimously. With no disputes to escalate, no fights to referee, nobody storming into a room to announce “this is bullshit” (that’s a different story).

It was about marijuana. And it went absolutely nowhere.

Some Background

A little Senate enthusiasm for legalizing marijuana was bubbling up in early 2017, and the White House Office of National Drug Control Policy (ONDCP) came looking for direction. What’s the president’s position?

I wasn’t aware he had one, and I didn’t have one to hand him either - which, if you know me, is… unusual. I show up to a policy meeting with a clear agenda and limited patience for dissent. But on the question of weed, I genuinely saw both sides. (That was then. Soon after, my kids became teenagers and my usual dogmatism came roaring back.)

So I asked the obvious question: what does the data say?

Nothing. We didn’t have any. ONDCP told me, kind of sheepishly, that Obama’s team had ordered federal agencies to stop collecting data on marijuana’s health effects. There was no current science on an increasingly popular drug. Super.

With nothing but vibes to work from, I convened a Policy Coordinating Committee and invited everyone with an “equity” in the outcome (White House lingo for a reason to care and the standing to make your life difficult if you leave them out).

I expected Health and Human Services (HHS) to have thoughts, and Department of Education. I did not expect nearly every agency in the federal government to raise its hand with a marijuana problem I’d never heard about.

State showed up to warn that going soft on marijuana would violate the international narcotics treaty - we were, in their words, “the last country holding the whole thing together.” Is that what you want, Katy? No. I hadn’t previously considered that legalizing a plant might unravel international law.

Treasury arrived with a story about Suspicious Activity Reports - paperwork banks must keep filing, every 90 days, for any account tied to the illegal drug trade. Since, it’s still federally illegal to sell cannabis, regardless of what Colorado said, that now meant that the HVAC guy in Oregon who services a dispensary, or the janitorial company that cleans one, get tagged as colluding with cartels. Banks were just closing their accounts instead of doing the filings. What do you want us to do, Katy?

Interior had cartels running illegal weed grows inside national parks - guys with Uzis, occasionally shooting a hiker who stumbled onto them. Clear them out and risk a shootout? Burn the crops? Airdrop pesticides on them? Fish and Wildlife, meanwhile, wants to know who’s cleaning up the pesticide runoff those same grows dump into the water table. I did not have strong opinions on any of it, but setting fires or dumping toxins in national parks didn’t seem awesome.

Customs and Border Patrol pointed out that hemp and marijuana are genetically the same plant, one just bred with less THC - so if the Senate legalized hemp (Senate Majority Leader McConnell was pushing hard for his state’s farmers), every truck carrying the plant over the border would need stopping and testing to prove it wasn’t carrying the illegal version. Congress solving one problem was about to hand CBP a much bigger one.

Transportation, which sets drug testing standards for bus drivers nationwide, wanted to know whether Colorado’s late-night party-bus drivers should get a pass for testing positive off insane amounts of secondhand smoke, or keep the current standard - screwing up non-using drivers’ records.

And then there was National Institutes of Health (NIH), which runs the sole government-sanctioned research weed farm in America, at Ole Miss. It’s the only legal source of marijuana for researchers in the country, and the product is derived from the weed on the street in the 1970s, so weak and outdated compared to what’s on the street today that studying it is basically studying a different drug. Worse, the hoops to get any of it are so brutal most researchers gave up, which is part of why we still didn’t have great data.

The hits kept coming, a dozen agencies deep.

And Then, a Miracle

We took all these normally warring fiefdoms - DEA, FDA, CDC, NIH, State, Treasury, Interior, Fish and Wildlife, Customs, DOD - through a set of policy recommendations, without having to escalate once from our level to the Cabinet-level people above us, and they agreed. On everything. Every single agency signed off.

So, we picked our moment. Kellyanne Conway (who was crushing it on the president’s combating opioid addiction initiative), as well as my DPC colleague who covered law enforcement, and I would brief the president, hopefully get his blessing, and hand the agencies the clarity they’d been begging for.

The meeting got scheduled. Then, it vanished off the calendar. “Scheduling conflict.” Ok, the president is a busy guy. Then, again. And again. For months.

Eventually I found out why.

Someone very close to the president - someone with one of those vague, ad hoc titles that were created outside the more formal org chart in the White House - had an equity we never knew about, and simply made the meeting disappear. Had we known, we’d have put them at the table and fought it out like men. Instead, it just died.

I never briefed the president on marijuana policy. Near as I can tell, nobody ever did. The most harmonious policy process of my career produced an airtight, unanimous consensus that went straight into a black hole.

So what does this have to do with why things aren’t happening on health care?

I used to tell that story as a fluke, the one time an unlisted stakeholder short-circuited an otherwise working process. But that process isn’t working anymore.

Inside every White House, and every agency’s political staff, there are two groups of staff, and which kind is driving the bus can change things quite a bit.

There are policy people - the subject matter experts (supposedly, LOL) who build the substantive case, weigh who wins and loses, and land on a recommendation. And there are relationship people - Communications, Political Affairs, Public Liaison, Intergovernmental Affairs, Legislative Affairs - whose job is to flag possible outside relationship threats posed by a policy and, once a policy is set, to sell it, rally the winners, and absorb the fury from whoever lost.

Policy people historically have led the process in every other administration, including the first Trump term. But the portfolio is so enormous, and the affected interests so numerous, that no policy shop can field every hysterical call alone - and if you leave the relationship managers out of the team, something you never saw coming could run you over. Policy, like politics, is a team sport.

The White House Org Chart

Every White House in recent decades has three policy councils: Domestic Policy (DPC - maybe a dozen people), the National Economic Council (NEC - about the same size), and the National Security Council, which dwarfs the other two combined - 300 to 400 people, roughly 80 percent detailees on loan from every foreign policy agency in government, maybe 40 to 50 political appointees mixed in.

Somehow DPC and NEC, in charge of the issues touching American voters most directly, each get an eighth of a hallway on one floor, while NSC occupies two (three?) entire floors of the Old Executive Office Building. Still aggrieved about this, apparently, ten years later!

Two more offices round out the building. The Office of Management and Budget (OMB) prices out the president’s agenda and approves every agency’s spending, and somehow manages to be despised by literally everyone else in government, usually (though not always) through no fault of their own.

White House Counsel tells you all the ways you can’t do what you’re trying to do. If they are sharp and aligned, they’re worth their weight in gold. If they’re bureaucratic or not aligned, a nightmare. Most of them are fast talkers, logical thinkers, and some of my most favorite people, who always helped us lawfully get to “yes” on the president’s priorities.

The Relationship Offices

Each manages exactly one type of outside constituency.

Public Liaison runs the outside groups - trade associations, pharma, hospitals, pro-lifers, farm bureaus. Need doctors and patients filling chairs at a Rose Garden event? OPL finds them. First Lady wants to visit a school? OPL picks the perfect setting.

Political Affairs handles donors, campaigns, and pollsters, and is one of the only offices allowed to be openly partisan on the clock, since the Hatch Act bans it for most others. Give enough money to the re-elect or inaugural committee, and this office might return your panicky call about a policy rumor coming out of HHS. They can also poll an idea for the president when he wants the politics, not just the substance, which sometimes helps your case and sometimes kills it.

Legislative Affairs babysits all 535 wild-eyed egos, committee by committee, usually staffed by former Hill aides who already know the players. Any Senator with a gripe usually calls their OLA contact first, not the policy person, since OLA juggles that member’s whole relationship with the White House, not just on one issue. Sometimes they might call the policy people directly, or the policy people might call them directly. OLA hates when this happens because you might blow up some unrelated ask the White House is already working with that Senator, mid-flight. Ask me how I know.

Intergovernmental Affairs liaises with the governors of both blue and red states, mitigating various state funding grievances, disaster declarations, supply chain problems and other important situations.

Communications counts as a relationship office too since the media can kill a policy before it’s ever formally voted on, just by drowning it in hostile coverage before rollout.

You want every one of these people at the table when policy is being made. Not necessarily for a vote, but for the early-warning radar about any restless natives or grassroots insurgency popping off outside the building.

The Hierarchy, and How Fights Climb the Ladder

The org chart undergirding this whole circus - the people heading each council or relationship office - are Assistants to the President, APs - cabinet secretary rank, no Senate confirmation required. Under them, Deputy Assistants, DAPs - deputy secretary rank. Under them, Special Assistants, SAPs - assistant secretary rank, and the designated subject matter experts. That was me: SAP for health care at DPC. Which meant, on my plate: all of HHS, social issues, and any cross-agency issues where health or social questions arose. Not to mention that NSC never staffed global health with a political appointee, so whatever health questions their people couldn’t answer landed on my desk to.

APs, DAPs, and SAPs, and their counterpart Secretaries, Dep Secs and Senate-confirmed Assistant Secretaries at the federal departments, are what are called “commissioned officers,” as identified in Article II of the Constitution, holding the only default seats in the formal policy making process. Which means, at some point, a fancy calligrapher (actual job at the White House) writes up your commission for the president to sign.

The policy process and the White House hierarchy are structured around the layers of commissioned officers. Everyone else gets invited at the discretion of whoever’s running it. Then there are the ad hoc, extra-special jobs every president gives to his closest advisors - various czars, “Counselors to the President” like Kellyanne, or the president’s own daughter and son-in-law - who are often important to have at the table, have invaluable feedback, or have equities and interests that will get shared with the president if you don’t accommodate them in the meeting.

The formal process is a Policy Coordinating Committee, starting at the SAP level: policy people from the White House offices, and the federal departments, as well as the relationship managers, counsel’s office, and OMB. Disagreement escalates one rung at a time - SAPs to DAPs, DAPs to APs, and if even that fails, straight to the president. That’s the theory - and, not coincidentally, the structure of my weed story, except it worked flawlessly and the result still got lost in space, because somebody entirely outside it had an equity we hadn’t realized.

Most of the real work happens before a committee convenes - weeks or months talking to agency people, outside groups, and, of course, the lawyers about what the statute allows. These are the Super Bowl of policy jobs: you can call the best expert or biggest celebrity on earth on nearly any topic, and because the White House is calling, they pick up. The meetings stay pretty informal on the domestic side, unlike NSC’s memo-heavy choreography, since we don’t have the staff to maintain the rigid paper trail they do. Usually ninety percent of the paper is agreeable to everyone; it’s the one or two live disputes that need working out.

Escalating is slow and expensive. Regulation can take two years to finalize, longer if sued, and a term only has four years. Every level has an incentive to compromise rather than kick it upstairs.

This is roughly how it’s worked under Bush, Obama, Clinton, Biden and even the admittedly chaotic first Trump term, all of them - not because anybody would call it a good time, but because it’s the best mechanism anyone’s found for making sure the president gets the best, most expert and most vetted advice before he decides.

All of that was how things usually work. It does not seem to be how things are working right now.

At least that’s my working theory about why policy-making in this White House has felt so sideways, so inconsistent week to week, so contradictory - frankly so demoralizing, at least on the health issues I follow closely.

Everything you’ve read so far describes how a White House is designed to make decisions. But that’s not how this White House operates. In the paid section, I explain what has replaced the traditional policy process, who now drives decisions, why the normal checks have disappeared, and what that means for governing. If you’re not seeing the rest of the article, you’re missing out on the best part! Consider upgrading. The rest of you, let’s get to the good stuff.

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Editor’s note: This is Part 3 of the series “How Do We Lower the Cost of Health Care in the U.S.? Need Less Health Care.” Part 1 changed the framework and how you think about healing. Part 2 covered what to do when something’s wrong, but not urgent, and the alternative pathways outside the conventional system. Part 3 covers what to do when you genuinely need a hospital, and how to choose one that won’t bankrupt you or make things worse.

I’ve already told you about my dying sister’s catastrophic night, strapped to a gurney and shipped across town at midnight because “there’s a bed open now.” I’ve told you about my daughter, three centimeters dilated and forced into an unbiological 12-hour deadline, because everyone’s on the birth assembly-line clock. Regular readers know I don’t romanticize hospitals. I’ve called them Soviet-style hellscapes, and I stand by it.

But this isn’t that article. This is the practical one.

Because despite everything we covered in Part 1 (get your mindset right, your body can do more than you think) and Part 2 (when something’s wrong, there’s a whole world of healers outside the white coat system), sometimes you actually need a knee replacement. Sometimes you get cancer and you want conventional chemo. Sometimes it’s a hernia repair.

When that day comes, you have a choice most people don’t realize they have: whether to hand yourself over to a greedy, bureaucratic, medically dangerous hospital system, or get the exact same care somewhere that won’t financially and clinically wreck you in the process.

The Tell

If you ever needed proof that hospitals are raping and pillaging their own communities, look no further than the hospital cost interactive tool, a delightful little playground built by the incomparable Marilyn Bartlett for the National Academy for State Health Policy (NASHP). The tool also feeds a wonderfully useful interface, Sage Transparency, that combines quality data with the NASHP cost data.

The tool pulls from every hospital’s actual, required financial filings to the government - because they wouldn’t lie to the government, right? Their real costs. Their liabilities and debts and private equity and hedge fund investments. Their charity care. Their mix of money-losing Medicaid patients, break-even Medicare patients, and commercially insured patients who are, in every sense of the phrase, the golden goose.

But the best part of the tool is the number it hands you called the commercial break-even rate - the percentage above Medicare rates a hospital would actually need to charge insured patients just to break even. No profit. Just breathing room.

Spoiler alert: that number is almost never higher than 50 percent above Medicare rates. So that’s what they’re charging, right? Because, they’re charities?

Not exactly.

Per the RAND Corporation’s ongoing hospital price transparency study, hospitals actually charge private insurers an average of 254 percent of the Medicare rate - outpatient services run even higher, at 279 percent. That’s a three-times markup over what it takes to survive, extracted from patients, employers and taxpayers.

But they’re dying, you see. DYING. They have to close their doors, dying! They have to send Grandma to collections, because, dying.

If these institutions were the white-hat charities their tax status pretends they are, they would charge no more than the commercial break-even rate to you and your plan. The fact that they routinely charge nearly double that or more tells you everything you need to know about who they actually are.

The Bait-and-Switch

At the end of the day, the “health care” system is dressed up as a haven of healing, when really it’s an altar of sacrifice demanding our dignity, our autonomy, our agency, and too often, our ability to get better. The medical system profits most when we are sick, sick for life, and have high-priced stuff done to us or bought for us. That’s the opposite of our own priorities, which are to be healthy, and to pay less. All the incentives in the system are aligned against those priorities.

We’ve discussed in this space before how hospitals are clinically dangerous hellscapes unfit for humans. But they are also deeply dangerous to our financial health. This is one of the main reasons Step Three of this whole series matters so much: stay the hell out of hospitals for non-emergencies.

Here’s the fuller rap sheet, in case you needed more convincing:

• They wave their “nonprofit” status like a halo - billboards at the ballpark, Jesus-adjacent mission statements on the website - while hiring the priciest management consultants money can buy to make sure as few poor patients as possible ever find out about the free financial aid they’re legally required to offer.

• They collude with insurers to force you and your employer to pay anticompetitive contracted prices instead of the (usually lower) cash price, and refuse to take cash from patients whose plans they’re contracted with.

• They charge you a facility fee for the privilege of walking through their doors - a fee an identical, non-hospital-owned building down the street doesn’t charge for the identical service.

• They’re rolling out AI in the exam room, marketed as freeing your doctor to look at you instead of a screen, when a good chunk of what it’s actually doing is mining the visit for more billing codes.

• They’ve eaten nearly every independent practice and facility in sight, using monopolistic, cartel-like tactics to erase competition - which is exactly what that DOJ lawsuit against OhioHealth was about (which OhioHealth recently settled).

• They exploit the 340B drug program (h/t ) - a safety net program designed to help free clinics and HIV providers stretch scarce dollars for poor patients - by buying drugs at pennies on the dollar and then billing plans and patients full price, pocketing the spread.

• They turn outpatient visits into revenue funnels, pressuring employed doctors to refer patients to pricier services inside the system, corroding the trust between doctor and patient and grinding down the souls of well-intentioned physicians in the process.

• They charge you whether they heal you, cure you, or make you worse - and they cover up the errors and the inhumane staffing conditions that produced them.

• They create the very complications they then bill you to treat.

• They hide their prices behind contract gag clauses and simply ignore the federal transparency rules when the fines are cheaper than the exposure.

• They prohibit self-funded employers from cutting a better direct deal with them than their insurer already negotiated.

• They’ve even gamed Medicare’s rural and urban hospital designations (h/t ) simultaneously - claiming rural status for one payment program and urban for another - to squeeze extra money out of both. HHS tried to force hospitals to pick a lane. A federal court struck the rule down.

• And of course, they lobby at industrial scale to smother any reform of these abuses, before it reaches a floor vote.

Despite this parade of horribles, sometimes (regrettably) you may actually need one.

What Hospitals Are Actually For

The system does have real, if narrow, uses. For a hospital proper, that use case is life-threatening emergencies.

• I have a bullet in my belly.

• I have a bone sticking out.

• I’m having a stroke.

• I’m having a heart attack.

• I’ve drowned and I’m unconscious and not breathing.

• My placenta is blocking the birth canal during delivery.

• I have a tumor blocking my colon.

As I’ve written before, these are exactly the services that aren’t profitable for a hospital, and can’t be made profitable:

“The life-saving, acute services that are valuable are not profitable. They cannot be made profitable. They require an expensive crew of high-skill labor, cutting edge technology, the most expensive forms of ground and air transport, with 24/7/365 access for a catchment area that does not produce enough of these needs each year to recoup costs.” from Hospitals are Soviet-Style Hellscapes Unfit for Humans

The Stuff That Actually Pays the Bills

The rest of the hospital enterprise - the part that really rakes in the money - isn’t curing or healing much of anything. It’s suppressing symptoms, slowing disease progression, or preventing some hypothetical worse outcome that hasn’t happened and might never have happened.

Think:

• Joint replacements

• Chemotherapy and radiation

• Mastectomies for breast cancer

• So-called transgender procedures

• Dialysis for advanced diabetes and kidney failure

• Cardiac cath lab procedures - stents, balloons, and the like

• Infusions for rheumatoid arthritis and other autoimmune disease

• The majority of C-sections - as I’ve written before, for every genuinely emergent C-section, there are roughly two more elective or unnecessary versions, scheduled around a clock and a convenience, not a crisis

Very little of what actually generates revenue in a hospital is aimed at healing, curing, or reversing anything.

Plenty of the surgeries on that list have been shown in rigorous trials to perform no better than a well-run placebo. Some cancers resolve on their own or in spite of the treatment thrown at them - though it’s genuinely hard to pin an exact number on that, because we almost never test what would happen with radical lifestyle change or emotional healing tried alongside (or instead of) the poison-cut-burn protocol. Nobody’s funding that trial.

None of this means these treatments are all garbage, or that nobody needs them. Once you’re standing in the clinical presentation these procedures exist to address, the window for other options may already be closed. I’m not telling you to skip your chemo or your hip replacement.

What I am telling you is this: not one of us wants to be the person needing this care. Every single one of us would infinitely prefer never to need it at all. That’s the whole premium proposition of health - not needing to ever darken the door of these institutions.

All of these treatments represent the failure of health care, not health care itself. They are sick care. Sick care is what happens after health care has already failed.

Should Hospitals Even Exist As We Know Them?

I’m honestly not convinced hospitals should exist as financially independent entities at all. As we just covered, the services that actually save lives can’t be made profitable without the kind of cravenly corrupt cross-subsidizing we just walked through.

Maybe hospitals should simply be allowed to be what they actually are: the known money-losing wing of a larger operation that profits when people stay healthy. Some employers have already started thinking exactly this way - floating the idea of building their own hospitals, designed from day one to lose money on emergency and trauma care, while the real value gets delivered through advanced primary care and world-class specialty care outside the hospital, in innovative, often physician-owned models.

Which brings us to the actual playbook.

If You Need a Hospital, Don’t Go to a Hospital

Ok, to be fair, if it’s a true emergency, go to the nearest ER, full stop, no footnotes. (PS if it’s a broken bone that’s not sticking out of the skin, try an ortho urgent care instead).

But if it’s not an emergency and you still need or want conventional medicine, the single most important decision you’ll make is this: don’t do it at your local hospital system, or at any facility with their logo on the door.

Hospitals have swallowed so many independent physician practices, imaging centers, labs, and surgery centers that finding the survivors takes a little effort. But they’re out there, they’re often physician-owned, and physician-owned facilities consistently post better outcomes than the hospital-owned version of the same service. Here’s the rundown, category by category.

Surgery

Outpatient, freestanding surgery centers exist for nearly every elective (the kind you schedule) procedure now - GI surgery, joint replacement, even a lot of cancer surgery. These are called ambulatory surgery centers, which is just fancy talk for a place you walk into in the morning and leave before dark. Some also keep a handful of overnight beds for more complex cases.

It is rare, at this point, for surgery to genuinely require a hospital-owned facility. A huge share of it is now done laparoscopically or robotically rather than the old rip-you-open approach.

• Google “independent, not owned by hospital, surgery center in [your area].”

• For orthopedic procedures specifically, ask AI: “is there an Ortho Forum affiliate near [your area]?”

• If you’ve already found an independent orthopedic practice for your consult (which you should - steer clear of the ones with a hospital logo on their website), just ask your orthopedist where the independent surgery center is that he personally uses.

If your surgeon happens to be hospital-employed, he’s going to schedule you at the hospital, and when you push back, he’ll walk you through all the reasons your particular risk profile is so special that, unlike normal patients, you can’t be operated on outside the hospital. Get a second opinion from a truly independent surgeon. That explanation is, more often than not, garbage.

If you want help finding the cash-pay option, a vendor like MDSave lets you shop surgeries, procedures, MRIs, and infusions for a transparent price. Use it to pay cash and submit to your plan afterward if you’d like - or just use it to find where the independent options near you actually are, then book there through your normal insurance if you’d rather not self-pay.

Infusions

Freestanding infusion centers are excellent for chemo and other infused drugs - like the ones treating rheumatoid arthritis, psoriasis, and other autoimmune conditions. They almost always take your insurance. Find one near you through the National Infusion Center Association locator.

Even better than a freestanding center: ask your health plan whether they’ll cover home infusion. It’s often dramatically cheaper and more convenient for a plan to send a nurse and the drug to your living room than to pay hospital or community oncology clinic rates. Search for a provider through the trade association’s directory.

So the pecking order is: home infusion first, freestanding infusion center second, and community oncology practice as your fallback if neither of the first two is available. Community oncology practices still tend to overcharge for the drug and its administration - but at least you’re not also paying hospital facility fees on top of it.

Imaging

MRI, CT, ultrasound, mammogram, DEXA scan, x-ray - whatever it is, stay away from a hospital system for it. Find a freestanding radiology facility instead. They’re usually named something like “[Your Town] Radiology,” or just ask AI to find the independent imaging center nearest you.

These places almost always take your insurance, and their cash price frequently beats whatever your plan is actually paying on your behalf. So if you’re still working through your deductible, don’t lead with your insurance card - say you’re self-pay, pay the cash rate, and submit the receipt to your plan afterward for deductible credit.

I also like RadiologyAssist.com for booking a cash-pay appointment at an independent facility near you - or just use it to identify where they’d send you, then book that same location through your insurance if you’d rather not pay cash upfront.

And if you do end up in a hospital and get hit with the bill you knew was coming, don’t just pay it. Go pull out my free playbook for outsmarting the medical billing trap and use every page of it.

We close our series with a review: the way to sustainably lower health care costs in this country isn’t a financing trick, a new middleman, or a better contract - those are all important whack-a-mole tricks staying one step ahead of the bad guys. The real solution is needing less health care - especially the kind that is bankrupting the U.S. and eating up almost half of every federal dollar.

That starts with living like a human, so fewer problems show up at all. When something’s wrong but it’s not an emergency - consider a partner in healing outside the white-coat paradigm. And when you truly need conventional care, get it anywhere except the Soviet-style hellscape on the tax-free real estate down the street, profiting from lifelong patients while pretending to be a charity.

Nobody in Washington is coming to fix this for you. The real revolution is what you do the next time a scheduler tells you where you “have” to go.

Editor’s note: This is Part 2 of a three-part series. Part 1 was about the mindset shift - recognizing that the way to lower health care costs is to need less health care, and that your mind is the most powerful healing tool you own. Part 2 is what to do when something’s actually wrong and a white coat isn’t your first call. Part 3 is about when you genuinely need conventional care, and how to get it without a hospital system bankrupting you or making things worse.

When last I last left you, I was making the case that the best way to lower health care costs in the U.S. is living like a human, and the health that follows. Real food, real sleep, real sunlight, real movement, real people in your life. When we can pull this off, a shocking number of problems simply never show up asking to be “fixed.” But given that you’re operating inside a human body living in a toxic world, sooner or later, something is going to break anyway.

This article is about what to consider when you know something’s wrong. It’s real, it hurts, and every instinct you’ve had installed since childhood is coaching you to just go to the doctor.

If you’re reading this, you already know that the system conditions us to outsource our healing to authorities and experts in white coats, to rely on the conventional doctors and hospitals covered by our insurance plans.

You also already know this system, and the “authority” and “expertise” we pay it to provide us, has presided over the last century of medicine, coincidentally the same period during which we have become the sickest, fattest, saddest, most anxious, most infertile population in human history. We are facing extinction-level chronic illness rates.

The solution to these problems won’t be found in the health care system that’s failed to prevent or reverse them at best, and that profits from and contributes to them at worst.

Of course, if you have a bullet in your belly, or a bone sticking out, a heart that’s stopped beating, or some other serious mechanical problem, there is no place you’d rather be than an American emergency department. But if it’s not an emergency, there may be alternative approaches outside the system worth consideration.

As I described in Part 1 with my own aches and pains, and my encroaching vision issues, that means breaking the habit of getting on the orthopedic surgery superhighway, avoiding diagnostic imaging (aka hex-casting), and not assuming that certain symptoms (like vision loss) are just inevitable with aging.

There are alternative pathways.

There are practitioners like homeopaths, classical osteopaths, traditional naturopaths, acupuncturists and holistic-minded chiropractors. There are also conventionally trained practitioners who have chosen treatment strategies that are outside the mainstream, like the neuro-optometry clinic I described in Part I, the formerly-licensed MDs who now practice at the New Biology Clinic, or integrative oncology centers who use many more tools than traditional poison/cut/burn cancer protocols.

But I’m here to confirm just one more thing you likely already know - when you step beyond the white coat, it’s the wild, wild west. I mean that as both a warning and an encouragement. There are healers doing things that will genuinely blow your mind. There are also people who will happily separate you from thousands of dollars while accomplishing nothing. And there is no directory, no referral system, no friendly gatekeeper to sort them for you.

The gatekeeper is YOU. (Which, if Part 1 landed at all, is obviously exactly how it should be.)

Six Questions Before You Hand Anyone Your Body (or Your Wallet)

Every practitioner on earth - licensed or not, ancient tradition or invented last year - is situated somewhere on a continuum, or several. Knowing where you want to be on each continuum is half the battle.

Let’s go through the process I go through when evaluating a practitioner I might want to engage with.

1. Who’s in charge here?

The white coat system operates on submission. You’re the child. They’re the adults. They have all the power and all the expertise, they make all the decisions, and if you disobey, you get shamed (and sometimes punished) for it. That’s one end of the authority continuum. We won’t go that far.

The other end is full agency: the practitioner contributes structure and guidance, but you run your own healing. This may be too much agency for many beginners.

But neither end is inherently wrong. If you’re fresh out of the conventional system, the expert-authority model may be what makes you feel safe - and feeling safe is itself therapeutic (I wrote about your brain’s bootleg pharmacy here). You’ll migrate along the continuum over time. Everyone does, but figure out where you are on the spectrum and what type of help you are looking for - today - before you go searching.

2. What is their license actually worth?

Something you might not have thought about is that a licensed practitioner’s actual client is the state.

The state has total power over that practitioner’s livelihood, so he’s going to be careful, and you will get a bit more governmental groupthink out of the licensed ones - not because they are evil, but because they’re humans with kids and mortgages of their own. In exchange, you get some degree of accountability (as in, a licensure board to complain to) and a much better shot at insurance coverage. That’s the trade off. There’s no right answer, just know what you’re buying.

Beyond licensure, there are certifications (which are of course a mixed bag - though I confess a soft spot for practitioners who never stop taking courses) and then there’s experience. Some of the best healers out there have no letters after their name at all. They got good the old-fashioned way: by doing it, over and over, on real humans who left a trail of glowing testimonials.

3. What do they think a symptom IS - and what are they measuring?

This divides the entire healing world. Camp one: symptoms are pathology, something has gone wrong, and the job is to make it stop. Camp two: symptoms are adaptations - your body doing something right in response to a toxin or a threat - and the symptom is the visible part of that response.

Notice: are they chasing your lab values, your waistline, or the radical metric of whether you actually feel good and function well? Some practitioners won’t rest until your bloodwork is beautiful even if you feel fine. Others take the view that if you’re thriving, we’re not going hunting for reasons you shouldn’t be. There are merits to both. Just know which one you’re hiring, and which one you need. (I’ve had my own “I don’t care what the root cause is, I need to function tomorrow” moments. I’m not judging you.)

4. How do they know what they know?

Holistic practitioners aren’t anti-science.

Many of them just value ways of knowing beyond randomized controlled trials. Things like observation of nature, thousands of years of accumulated clinical pattern-matching, and intuition. Meanwhile, the trial-and-evidence crowd will tell you exactly what the latest study did and didn’t show (although often they fail to notice the garbage study design). This can be genuinely valuable, right up until you remember who funds most of the trials and how negative trials don’t get published in the journals.

As a practitioner, I try to consider it all. But everyone has a bias here, including your humble correspondent. Ask about theirs. You need to know.

5. How rigid is their framework?

An acupuncturist operates inside Traditional Chinese Medicine, a gorgeous, ancient, meticulously mapped system. She is not going to give you stretching exercises or prescription meds, because that’s not her framework. An energy healer may not notice that your elbow hurts because the bone is fractured, because fractures aren’t in her framework. Just like the functional medical doctor is going to lab you into oblivion and might miss the childhood trauma at the root of your autoimmunity.

The single most practical thing I can tell you is to understand what each practitioner sells, and don’t go trying to buy eggs at the hardware store. The hardware store sells hardware. It will not notify you that it’s out scope. It will simply keep speaking with authority. Knowing the boundaries of someone’s framework is your job, not theirs.

6. Is the healing done TO you, or BY you?

Some modalities are receptive. You lie there and you receive - bodywork, sound, frequency, prayer, laying on of hands. Others are active (eg, nobody can do your breathwork for you).

They both matter.

In fact, receiving matters more than our do-it-yourself culture wants to admit because a lot of what turns your symptoms on in the first place is running on subconscious processes, things like fight-or-flight programs responding to threats you’re barely aware of. Your conscious mind can’t switch off what it can’t see. Receptive modalities can rattle loose what your conscious mind can’t yet reach.

My strong recommendation is to pair one active modality with one receptive one. Because it’s very possible that the combination outperforms either alone.

And now, finally, the who’s-who, from most familiar (feels like a doctor’s office, only better) to the most woo (you’re running the show).

The descriptions of practitioner types in the Field Guide below are stereotypes, lovingly deployed. Individual practitioners vary wildly, which is why you’ll be doing homework on every single one.

Next: The Field Guide.

Everything above this line was deconstructing how to think. Everything below is about knowing who to call.

In The Field Guide I outline the entire landscape from functional MDs and classical osteopaths (sorcerers, I’m not kidding) to homeopaths, naturopaths, Traditional Chinese Medicine and Ayurvedic practitioners, herbalists, craniosacral therapists, energy workers, formerly licensed physicians, and the full-woo frontier.

Plus, how this works with insurance (and how it doesn’t) as well as a few cheap back doors and my field-tested rules for not getting fleeced. Paid subscribers get the full download.

(If you’re not joining us for this next part, no hard feelings - I’ll see you next week for Part 3: what to do when you genuinely need conventional care, maybe even a hospital, without letting the Soviet-style hellscape known as your local hospital bankrupt you.)

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Editor’s note: This is Part 1 of a three-part series. Everyone from the White House to your HR department is trying to figure out how to lower health care costs. They’re mostly asking the wrong question. The real answer isn’t about financing mechanisms or which insurance company gets the contract. The way to lower health care costs is to need less health care. Part 1 is about the mindset shift that makes that possible. Part 2 is about what to do when something’s actually wrong - and the system isn’t your first call. Part 3 is about when you genuinely need a hospital, and how to choose one that won’t bankrupt you or make things worse.

It had been the hardest “leg day” with my trainer I’d ever done.

I was proud of myself.

But later that day, the inside of my knee started hurting badly. It was brutal. I couldn’t even bend my knee without sharp pain, even touching it hurt. Knees, it turns out, are load-bearing. Inconvenient. I figured resting and elevating would help. But when it didn’t, of course, I started researching. The symptoms matched the signs of a meniscus tear, and my chiropractor later confirmed he suspected the same.

The usual treatment for this injury is meniscus repair surgery - where the doctor “shaves” the frayed ends of the torn meniscus. But I remembered how often, when surgery for various ailments was put to the most rigorous standard of a randomized controlled trial using “sham surgery” in the control group, outcomes from the placebo effect were often equally effective.

A few weeks later, the 10-year follow up report from the FIDELITY study of long-term outcomes from meniscus repair (the “shaving” procedure) surgery compared to sham surgery controls, would come out in the New England Journal of Medicine, demonstrating that the treatment was no better and probably worse than the sham surgery, both in the short and long term outcomes of interest. At this point, I hadn’t seen that study. I’d only seen enough similar ones to know that my mind was the most powerful healing tool and that it should at least be tried before heading into surgery.

Because of this, I didn’t even want to get an MRI to confirm my diagnosis.

Many MRI studies have shown that “abnormalities” appear in asymptomatic people so frequently that MRIs are not particularly useful in determining the cause of symptoms. However, MRIs are extremely useful at making you think the abnormality is the cause of your symptoms and getting you to pursue high-revenue surgical and other treatments.

In other words, an MRI finding can serve as a “hex” that makes you blame your symptom on some structural defect or injury or degeneration and assume that only an expensive white coat can “fix” it. This is disempowering thinking in the extreme, and unsupported in many cases by the evidence.

I didn’t want my mind polluted with the notion that my body couldn’t heal itself before I’d given it a chance.

So I rejected the hex.

I went regularly to a chiropractor and an acupuncturist for a few weeks. Their manipulations brought good circulation and energy to the location, followed by symptom relief - often temporary or slow. But after about two months, I was 95% better. Four months later, I could barely feel anything there at all.

My mind is frigging amazing. So is yours.

The Real Answer to the Cost Crisis

Health care costs are eating our economy.

It’s a multi-trillion dollar industry that is nearly a fifth of the GDP. Every business, every state Medicaid director, every family at the kitchen table - we’re all sucking wind from the gut punch of health care bills.

Our solutions are generally in the same genre: financing.

Who pays? How do we shift costs to someone else? Which middlemen can we cut out? These are legitimate questions and I’ve spent most of my career on them (including my current day job as a CEO building ethical health plans for employers). But admittedly, they’re deck chairs.

The ship is sinking because Americans are sicker than we’ve ever been - and getting sicker by the day with chronic disease driving roughly 90 percent of our health care spending. You can’t finance your way out of a demand problem. We can shuffle who writes the check, but when the demand keeps rising, the supply will get more and more expensive.

But what if some fraction of us just needed less care?

The benefits might even go beyond saving the country money. Real agency would invigorate the Don’t-Tread-On-Me American spirit. And it wouldn’t take everyone - a minority could make a huge difference. That kind of shift starts in our mind before it takes effect on our body and our wallet.

So, Back to My Aches and Pains

I’m now dealing with a similar situation with a hip/groin muscle pain.

My hip feels like it constantly needs stretching and that starts to hurt when I’m walking a while. If I don’t rest, it becomes debilitating pretty quickly. I did some acupuncture. But then I discovered something much more effective. Something that sounds so unhinged, I’m slightly embarrassed to type it. If I stop focusing on the pain in the area and instead imagine what it would be like to be completely free from pain, and repeat a certain mantra, I can turn the pain immediately off.

The mantra alone isn’t the trick - it’s choosing to feel the feelings I’d feel if the mantra were true. The mantra is: “my muscles and joints are as limber, flexible and fluid as a child’s.” This isn’t just repeating something I don’t believe. It’s choosing to imagine what it would be like - what it would feel like - if it were really true. When I do this, the pain - literally instantly - disappears. This lets me walk further than I could before, and meanwhile work on the actual root cause - core weakness - by strengthening everything around the area.

I know how this sounds. I’m a health policy type, not a crystal-waving shaman. And yet. I’m not saying this will work in all cases, just that it has been extremely helpful for me.

The Vision Thing

Another thing your mind does - it sees.

My vision was disability-grade for the first part of my life until I got LASIK in both eyes in my 30s. Fifteen years of perfect vision followed and I was super spoiled. Then a few years ago, the nearsightedness started developing again and getting a little worse over time. I refused to give in to this, and I would only wear glasses when it was essential in certain situations.

I also noticed that my vision wasn’t uniformly the same all the time. Better in the sun. Better outside, full stop. Better off screens. Some days, perfect at sunrise; some days, terrible. This was data that challenged the programming I’d absorbed since childhood: stronger prescription every year, nothing you can do, just keep buying new glasses like a good little patient.

I learned about the Bates Method, a series of exercises that helps improve your vision.

And I discovered an alternative, out-of-the-system neuro-optometrist who has put the Bates Method on steroids and, through intensive and consistent exercises that challenge and exhaust my eyes, is beating back the creeping myopia monster that would otherwise be coming for my vision. The philosophy behind the program is that it’s your brain that sees, not your eyeballs. Your eyes are merely the receivers of the signal, it’s your brain that organizes that signal. With practice, your brain can do a better job. Vision happens in the brain and the mind can train it.

I’m beginning to suspect we’re all Jedis in waiting.

I don’t share all these stories to engage in medical exhibitionism or to present myself as some sort of guru who doesn’t understand the agonizing symptoms you’re having. Sometimes the symptoms are so bad that you need some mechanical or pharmaceutical relief while you’re working on your Jedi mind tricks.

This is a work in progress for me too.

I rolled an ankle recently and was in such agonizing pain that I popped two Advils along with my homeopathic Arnica remedy. That ankle healed overnight - literally - and I won’t pretend it was all Arnica and not the Advil. (I have documented at length how dependent I was on Advil in my excruciating pre-menopausal years.)

Now, I’m not suggesting that you should meditate your way out of cancer or Alzheimer’s. Once you’re down the road of a serious illness, it can be difficult or impossible to overcome the system’s programming and take on an illness in a radical way, outside the system.

For most people, the time to swim isn’t when you’re drowning.

The fact is, many of us are deeply committed to dependence on the health care system, despite the evidence that it has failed to reverse the diseases that are actually killing most of us. Most people hit the urgent care or the doctor with every complaint, small or large, and do exactly what that doctor says, take every pill he prescribes, and undergo every procedure he orders. That’s what I did for most of my life.

But what we don’t often stop and consider is that this instant symptom suppression system robs us of the opportunity to let our bodies finish what they’re trying to do - more complete healing. Almost all medical systems older than a few hundred years - such as Ayurvedic, Traditional Chinese and homeopathic frameworks teach insistently that when we suppress symptoms, they burrow down into a deeper organ system than they started, creating more significant illness. Eczema turns into asthma, which turns into an autoimmune condition and similar patterns.

It’s also how we got to a state where half the population are medicated just to get through the day. One in four of us are on three drugs or more. And about a seventh of us are on five or more, according to the CDC. Even more heartbreaking is the impact on children - almost a third of school-aged kids now have a chronic illness.

We spend more on our failing “health care” system than any country in the history of humanity. A report put out by a Johns Hopkins research team (full disclosure, I’m also a co-author) revealed that almost half - HALF - of taxpayer money goes to health care programs.

Now some of us genuinely believe the system is the only thing keeping us alive - a drug cocktail, a surgery, a procedure that’s holding something catastrophic at bay. Those people are not my primary audience here. And they may well be right.

Maybe the drugs, radiation, surgeries, stents, amputations, dialysis and organ transplants really and truly have saved their lives, once the health conditions requiring those responses were well established in the body. Many of them may have a good case to make.

Then there’s another set of people who wrongly credit medical treatments for saving their lives, but their bodies are healing in spite of the system’s interventions. And their minds are just as powerful as all human minds are, which means that their bodies might be responding to all this intervention, in part, because of that belief. (I wrote about that phenomenon here.)

I’m not interested in taking medical treatment away from anyone, nor am I trying to talk people out of what they think is (and what might actually be) critically important medical intervention. No. Instead, the more appropriate time for a radical mindset shift is before the system programming and all its interventions have their clutches too deeply into us. Before we’re totally dependent, either by virtue of reality or perception (or both).

We don’t need everyone’s buy-in to save America from health care insolvency.

If even 10 or 20 percent of Americans chose to opt out of the system whenever possible (like for non-urgent, non-life or limb threatening situations), that might be enough to change the fiscal and clinical trajectory our country is on.

What do I mean by “opt out of the system?”

There’s a continuum of system involvement.

First, let’s stipulate that when you have a life-threatening emergency, you should seek emergency stabilization, of course. But on the other end of the continuum, for most health conditions that arise, you can seek methods for healing outside the system. And in between, there’s the harm reduction approach, where you use the system when necessary - but the least harmful version possible.

Here’s the playbook in three parts:

1. Prevent illness by living like a human. We have species-specific requirements for food, hydration, sleep, movement, sunlight, contact with nature, tribal connection and spiritual practice. In this way we can minimize the health problems that arise in the first place.

2. Treat non-emergency health problems outside the conventional system, whenever possible (we will cover alternative options in Part 2 of this series).

3. When you truly need conventional medical care for non-emergencies, get it anywhere but a hospital system (more on that in Part 3 of this series).

Step One: Live Like a Human

A lot of our health problems arise because we don’t want to invest time, money and energy into our health. We live in a quick-fix, outsourced-authority, comfort-forward culture where if something bad happens in our life, we want some expert to turn it around as quickly and painlessly as possible.

That means that we a) “medicate” our problems away - so we don’t have to feel unpleasant feelings or think unpleasant thoughts. We do this with food, booze, sex, and escapist entertainment such as social media, TV, video games, porn. When the results of this stress suppression come for us, we b) medicate the problems created by our previous “medicating” our problems - we want a pill, a surgery, a life-hack.

But we already know that things that matter the most and that are the most valuable in life require major investments of time, energy and money.

Most of us have already bowed to this reality.

We worked our asses off in school or by paying dues on the job to get to a place where we can reliably pay our bills and achieve financial security. That security is worth the sacrifices we made and continue to make.

Another example is parenting. Having children, while it starts in a pretty fun way, will absolutely destroy you in ways you couldn’t have predicted. And most of us would do it again without blinking, because there is no greater value than children, their success and opportunities and the joy of grandchildren. Also, the bragging rights.

Many of us place a high premium on eternal life too - as well we should - after all, it’s a hell of a lot longer than our earthly life, pun intended. Many of us sacrifice mightily throughout life to pursue spiritual growth and fulfillment - through our time, money, and self-denial.

So why do we think that something as valuable as our health should require less? Part of the answer is that we’ve been gaslit by the white coat religious cult that they are the priests and they are the experts and they have the magical elixirs and that no one else on earth has any wisdom, expertise, or authority over your health except them. This is dangerous voodoo that will get you an early death.

First of all, no doctor cares about you even a fraction of how much you care about yourself.

Second, as we’ve documented extensively in this space, many doctors do a lot of quackery.

• “Don’t worry about that myocarditis, sleeves up, mate.”

• “Just take hormonal birth control for twenty years and that endometriosis definitely won’t ruin your fertility.”

• “Eggs are definitely bad for you.”

• “Don’t give your toddler peanut butter or he’ll get peanut allergies.”

• “Fetal monitoring definitely is associated with better birth outcomes.”

• “This surgery is definitely better than placebo effect.”

And on and on with many other lies, damn lies and other statistics.

And God forbid you end up in a hospital, where very little improves and you’re lucky to escape better off than you came in, if you escape at all. People often ask me, having been lobbied by all the health care special interests during my time in government, who the biggest Bond villains are in health care. It’s the so-called “nonprofit” hospital systems, not even close.

Third, the business model is aligned against our own priorities.

Most doctors and all hospitals are paid only when sick people show up for a visit. While I’m not saying that your doctor is out to get you, the entire health care industry does better when you’re sick, you’re sick for life, and they charge you high prices to do stuff. But you want to be healthy, to get better quickly when you’re sick, and to pay less. So these sets of values are mutually exclusive - only one can win.

The good news is - you have WAY more power than you think to avoid some of the most common illnesses that steal your quality of life.

As I mentioned earlier, we have species-specific requirements for food (real, not fake, found in nature, un-poisoned), hydration (un-poisoned), sleep (7-9 hrs), movement (way more than you are now), sunlight (in abundance starting in the morning, without glass between you), contact with nature (frequent), tribal connection (daily) and spiritual practice (consistent).

These are not optional. They aren’t “wellness tips.” They are the operating requirements of the human animal. Neglect them long enough and you will get sick. Stay sick long enough and you will die early. The medical system will be delighted to help you do both, at great expense to you and your estate.

The MAHA movement, including its policy agenda, is largely focused on this. To be honest, if this were all we all ever focused on, I would still call that a major win.

I’m a work in progress here, so don’t feel judged. I still drink Diet Coke too much - though regular readers will be proud that I no longer keep it in the house. Getting to sleep on time is still a struggle some nights. And well, I like Nutella, Ben and Jerry’s, and pizza way more than I feel comfortable admitting.

But since changing my mindset to take radical agency over my own health, many things have changed in my life. My biggest win has been figuring out how to stay disciplined with workouts - a lifelong struggle until my late 40s. And we now only bring organic food into our house, so our toxic exposure has been dramatically reduced.

You will have your own struggles and your own wins. But the mindset is everything here. Recognizing just how much of our health is in our control and choosing to guard that health as one of life’s greatest duties will change more than just your health - it’ll change your life.

Nota bene: there are so many conflicting and contradictory messages out there about food, hydration, movement, etc, that when you start to try to take control, you will be confused and won’t know exactly which philosophy to adopt. All I can say is to just start with what resonates and makes sense to you. As you experiment and are moving forward, it’s ok if your approach shifts over time - expect it, even.

(If you want help sorting through the noise, that’s what I’m here for!)

Book A Visit

Nobody’s coming to save us from Washington, DC. There’s no revolution to be found in your insurance card or your doctor’s office.

The real revolution is the moment you stop assuming your body is broken and start asking what it’s trying to tell you. The future of American health care system depends less on what that system does next than on what each of us does tomorrow morning.

FDA has just tipped its hand on peptides, and the hand is a losing one for the hundreds of thousands of Americans who depend on naturally-occurring, non-patentable peptides to relieve pain, heal injury, speed recovery, and generally improve health.

The agency just released a briefing memo laying out its intention NOT to allow peptides to be authorized for sale by pharmacy compounders.

Despite the fact that there’s a critical meeting of the FDA’s Pharmacy Compounding Advisory Committee (PCAC) on July 23-24, and despite the fact that relevant evidence for that meeting isn’t due to be submitted by either proponents or opponents of peptides until July 9th, the FDA has pre-determined its decision.

Now, to be clear, FDA is not bound to take the advice of the committee.

Even if every health-optimized peptide enthusiast bikes, swims, or sprints to the meeting from across the country and storms the meeting in barefoot shoes and organic boxer shorts.

But it’s pretty defiant that the FDA didn’t even pretend to consider public input on the question before telling the world that they fully intend to deny Americans access to these peptides.

Sadly, it’s unusual for the agency to change its mind once they’ve committed pen to paper like this.

Even though they’re about to receive the data from three US-based randomized controlled trials showing flawless safety data on American study subjects. Even though the president’s pet pollster has made it abundantly clear that approving peptides polls at above 60% among Republicans, Democrats and Independents, especially among middle-aged women - a critically needed demographic.

Peptides Rv Survey Memo 6 29 2026

1.12MB ∙ PDF file

Download

Download

Even though ground zero for peptide use and manufacture is in Texas, where Republican Senate candidate is in the race of his life and could use the help.

Nonetheless, I’m told by multiple sources that White House staffer Heidi Overton MD, a health advisor on the Domestic Policy Council, gave the green light to FDA on this position. Public release of the agency position - pushed by Pharma-friendly deep staters at the FDA - came as a shock to the (slightly) more MAHA-sensitive FDA political leadership.

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This seems like yet another gift to Big Pharma, who doesn’t want competition from compounding pharmacies creating useful products, based on natural substances, and selling them directly to consumers outside the insurance system.

Perhaps one explanation is that PhRMA - the industry’s powerhouse lobbying group - is apparently on the hunt for a new top lobbyist. Rumors are swirling that half the brain trust of the top health officials in the administration have applied for the $8 million a year job. Interviews start next week. Guess we’ll all have to sweat out the MAHA betrayals until the horse race is over. Sigh.

Right now - as in, at the very moment of publication - a group of economists and pharma-friendly policy types are sitting down to lunch, bankrolled by Pfizer (I was told privately), in Washington, D.C. to discuss a draft Executive Order (EO) that would hand the pharmaceutical industry everything it has ever wanted and then some.

I was invited to this lunch.

I sent my deepest regrets. I’m writing this instead.

The event is hosted by Unleash Prosperity Now, the think tank founded by Steve Forbes. The featured guests are Steve Moore (former presidential economic advisor) and Tomas Philipson (former Acting Chair of the Council of Economic Advisors, and apparently the academic health economist behind this draft EO).

Now you might be wondering why any of us should care what a roomful of think-tankers, Pharma bros and ex-Trump advisors say to each other over lunch on Pfizer’s dime.

The very real concern is that these aren’t cranks shouting into the void. The powerful people who show up in rooms like this are serious players with strong ties to senior officials at the White House, at HHS, and the president himself.

And those ties aren’t just hypothetical. A draft cooked up by outsiders becomes real policy when someone on the inside thinks it has merit, picks it up and runs with it. One day it’s being passed around a salon luncheon. The next, it’s got the president’s signature on it.

I know, because I have my own version of that story. It’s how price transparency came to be. Pointing out this method isn’t a knock on anyone. It’s how good policy gets made, too. The difference is what’s getting pushed. That one was a populist issue, despised by industry interests, that polled at 90 percent with voters. This one is a wish list for Big Pharma and Well-Connected Biotech. Paid for by Pfizer.

It’s billed as “an intimate salon luncheon” to discuss “the extraordinary economic promise of curing cancer” and “modernizing the FDA so that regulatory pathways keep pace with today’s scientific realities.” Who could be against curing cancer or keeping up with science? I know this language.

I’ve spoken this language. I know the free-marketeering policy that it is code for - which I very often have agreed with over the past couple decades in conservative policymaking. But the Shakespearean flaw of laissez-faire economics is its knee-jerk defense of private industry interests in health care - even when, as in the case of the past decade or so, that industry has become increasingly indefensible.

So I read what’s actually being proposed. Then I read it again, because I couldn’t believe my eyes.

And then I wrote 34 ranting comments in the margins.

The metadata of the draft EO lists Tomas as its author, which of course doesn’t mean he doesn’t have other collaborators. I worked alongside Tomas in the first Trump White House. He’s committed, credentialed, and about as laissez-faire as they come - a University of Chicago health economist who made his bones arguing for policies just like those in the draft EO - less and less FDA as the key to more and more Pharma products.

The draft EO was attached to the invitation to this lunch as the actual subject matter to be discussed. It has a name: Advancing Cost-Cutting Treatments and Diagnostics for Old-Age Populations through “Operation Warp Speed 2.0.”

(Paid subscribers can read it for yourselves here.)

Where to Even Begin

Before we get into the substance, the name alone will doom this proposal with public opinion.

The president gets booed at his own rallies, by his most diehard supporters, when he brings up Operation Warp Speed. There is no constituency in the United States - not Republican, not Democrat, not MAHA, not libertarian, not the guy who got the shot or the guy who didn’t - who is enthusiastic about resurrecting that program. Operation Warp Speed and all it delivered to the world is one of the most politically radioactive policy episodes of the last decade, and whoever suggested that branding either doesn’t read the news or wants the president’s polling to crater.

But the name is obviously just the first of many tone-deaf self-owns in this document. Let’s go section by section.

The Founding Myth

The EO’s opening premise is that medical innovation is the key to controlling the federal debt. If we just cure cancer and Alzheimer’s, the argument goes, we won’t have to cut Medicare - we’ll have a healthier population that doesn’t need as much of it.

This sounds good. And if we actually cured Alzheimer’s, cancer, and the other diseases consuming Medicare’s budget, it would be true. But pharmaceutical innovation and disease elimination are not the same thing.

We have had unfathomable medical innovation over the past century. More drugs, more devices, more diagnostics, more interventions than any previous civilization could have imagined. And what do we have to show for it on a population level? We are chronically sicker, fatter, more mentally ill, and more infertile than any previous generation in human history. The extinction-level chronic disease crisis that is actually bankrupting Medicare is not a failure of pharmaceutical innovation. It is the predictable outcome of dehumanized, unbiological lives - of industrial poisons masquerading as food, sedentary routines disconnected from nature, epidemic sleep deprivation, chemical exposures, and severed social bonds.

Medical innovation is not the answer to these problems. It is, at best, an increasingly expensive way to manage their consequences while the causes go unaddressed. Even if you concede that some drugs are keeping people with significant disease alive a little longer - which may be true - that would only perversely drive costs up, as these expensive new therapies generally manage or extend decline during the most expensive end-of-life years, but don’t cure.

And the dirty little secret is that “innovation” has become the industry’s word for obscene launch prices.

When a drug company insists that a new therapy deserves a $400,000 annual price tag, they justify it by saying - there was R&D involved, there were trials, there was a regulatory process. What they are not telling you is how much of that R&D was publicly funded, how taxpayers will be footing the bill for these products used by Medicare beneficiaries, and yet, how completely the profit is privatized once the product hits the market.

If the past is any preview of the future, there is no universe in which this dynamic controls the federal debt. It accelerates it.

The EO describes Operation Warp Speed (v.1.0) as an inspiration. I’d like to offer some alternative framings:

The tens of thousands of deaths attributed to the vaccines. The epidemic of myocarditis in young people. More than a million adverse events reported to government surveillance systems called V-safe and VAERS. The Pfizer trial in which there were more deaths in the vaccinated group than the unvaccinated group - and we approved the product anyway, because Warp Speed. The systematic delegitimization of existing treatments that might have helped people but were made of molecules too old to be profitable.

I’m not interested in re-litigating the entire COVID response here (though you can read more of my thoughts on it elsewhere). But if the lesson your team drew from that experience is “let’s do that again, but for cancer,” you’ve spent too much time in the faculty lounge.

The Structure - Who’s Running This Thing?

The EO would establish an Operation Warp Speed (OWS) 2.0 Steering Committee to be headed by Secretary Kennedy and his key agency heads.

Secretary Kennedy.

You know, Robert F. Kennedy, Jr.

Who literally wrote a book trashing OWS 1.0.

The Steering Committee gets better. It also explicitly includes pharmaceutical and biotechnology companies, among others, who would direct and oversee the OWS activities.

In other words, the regulated entities would sit on the committee telling the regulators what to do.

This isn’t a new idea. It is, in fact, the defining feature of regulatory capture - the thing that RFK Jr. has spent decades fighting, the thing that MAHA exists to dismantle, the thing that former Commissioner Marty Makary named as a foundational problem when he walked into the FDA, long before he was shown the door.

The EO summons another agency to the Steering Committee: BARDA, aka the Biomedical Advanced Research and Development Authority. You know, the shadowy, Pentagon-adjacent slush fund dressed up in public health clothing where sole-source contracts, guaranteed taxpayer pre-payment for unproven technologies, and relationships of unusual coziness with favored companies have determined who gets billions and who doesn’t.

What could possibly go wrong?

But the Operation Warp Speed (OWS) 2.0 Steering Committee isn’t the only committee this EO would establish.

The New “Advisory Committee on Expanding the FDA Mandate Beyond All Recognition”

Ok, that’s not really the name.

The EO would also create a permanent FDA Advisory Committee on Economic Innovation and Impact - a body of health economists, regulatory experts, industry representatives, biomedical entrepreneurs, and (for cover) patient advocates. The committee would be tasked with evaluating the economic consequences of FDA regulatory decisions and would require the FDA to respond in writing to any finding it declines to adopt.

Let me translate this: instead of asking whether a drug meets the scientific standard for approval, FDA would be pressured to ask whether enforcing that standard might hurt the industry’s (or anyone else’s) economic interests.

FDA’s statutory mandate from Congress is to protect the public from dangerous and ineffective products. Full stop. It is not to goose the GDP or pom-pom American biomedical competitiveness. It is not to weigh the complex economic ripple effects of its safety determinations. It is not to answer to industry representatives who are unhappy that their products didn’t get approved fast enough or that their garbage data were uncompelling.

The idea that an agency entirely organized around making scientific determinations about medical products has the institutional competence to accurately model all the downstream economic consequences of its licensure decisions is, charitably, delusional. No government agency could pull off such a sweeping set of mandates. And more to the point: we shouldn’t want it to try.

Picture the committee - stacked with regulated companies and their pals, now empowered to demand that their regulators consider the economic harm to their companies as part of the drug approval process. FDA’s independence has been in question for quite a while - in the last year, it’s been on life support. This would render it a complete fiction.

The draft EO reassures us that the committee members would be subject to “standard federal conflict-of-interest disclosure requirements.” But this is a joke - the committee is conflicted by design. The purpose of putting industry on the committee is to have industry’s interest overtly represented and to bully the FDA scientists with it.

Also worth imagining: this committee gets inherited by a future administration with completely different politics. Imagine President AOC, who decides that a drug’s anticipated launch price is itself grounds for withholding licensure. Because, economic impact. You’ve just built them the playbook - congratulations.

The Regulatory “Modernization” (Read: Weak-sauce Safety Trials)

Under the advice and oversight of all these committees, the draft EO would require:

• Creating fast-track pathways that cut development and approval costs by at least 50% while “maintaining standards of safety and efficacy.” You can’t cut the cost and time of safety evaluation by half and then claim you haven’t touched the standards. Sufficient follow-up time to detect safety signals IS the standard.

• Approving drugs that show “favorable safety with limited efficacy data” and then “further confirm safety and efficacy” later, by collecting more data after approval. But of course, shorter timelines make it less likely that we’ll know anything at all about safety, not more. This is the same trade the industry always wants: weaken and shorten pre-licensure requirements in exchange for post-licensure promises. Once a drug is on the market and a manufacturer blows off its post-market obligations, FDA is quite hamstrung in terms of what it can do without incurring the wrath of lawsuits and patient revolt. I don’t want to have to “further confirm” safety after licensure. I want safety fully confirmed before licensure. That used to be the whole point.

• Establishing a quota: prioritize approval of at least three breakthrough therapeutics by June 2028. This is not how regulatory science is supposed to work. If products meet the statutory standard, they get approved. If they don’t, they don’t. Setting an approval quota in advance is just explicit pressure on regulators to cut corners to meet the number. If you don’t believe me, ask Drs. Marty Makary, Vinay Prasad, Tracy Beth Høeg, and every other FDA scientist who has faced industry pressure to lower their standards.

• Streamlining biomarker validation and surrogate endpoints for drug approvals. In other words, use change in some lab result as the outcome studied in the trial instead of, you know, actual improvement in health or mortality. I will be generous here: there are some biomarkers that are genuinely well-validated and useful as surrogate outcomes. But the track record on aggressive use of surrogates to speed approvals is not inspiring. Too many drugs approved this way improved the surrogate but were later discovered to have no impact on the clinical outcome (or to make it worse). Oncology drugs approved on progression-free survival that never demonstrated improved overall survival. The Aduhelm debacle for Alzheimer’s. The emerging scientific consensus - supported by decades of hard experience - is moving toward more rigor on surrogate validation, not less. This EO proposes to move in the opposite direction, and it does so, not because the science supports it, but because it lowers costs for drug makers.

Taxpayers as Insurance Policy and Piggy Bank

The EO directs NIH, BARDA, and the VA to use their contracting authority to “support late-stage trials and secure early access to promising candidates.”

If you don’t speak pharma gibberish, that means: transfer the financial risk of pharmaceutical R&D from private companies - who will capture all the profit - onto taxpayers, who will capture none of it. The companies bear the upside. The American public bears the downside. These frameworks have historically generated sole-source contracts, sweetheart deals for politically favored manufacturers, and guaranteed government pre-payment for unproven products.

As with so much else in this EO, we need less of this type of corruption, not more.

The Coverage Mandate

Buried in the coverage provisions is this: “CMS shall ensure that Medicare beneficiaries can access OWS 2.0-designated products within 30 days of FDA authorization.”

A drug gets FDA authorization under the accelerated approval pathway - meaning it has shown “favorable” safety (whatever that means) with limited efficacy data, remember - and within 30 days, Medicare must cover it. Before the “evidence development phase” tells us whether it actually works or has been followed long enough to be deemed safe.

This is guaranteed procurement by one of the planet’s largest single-payer systems, for under-scrutinized products at obscene launch prices, backed by the full faith and credit of the United States Treasury, with a 30-day clock that ensures there’s no time or leverage for the government to ask the hard questions or negotiate reasonable terms and conditions.

I’m old enough to remember when Republicans - especially Republican economists - argued that coverage mandates drive up the cost of health care.

And… Brace Yourself

Attention, MAHA: the draft EO calls for “ a rolling review process with clear timelines… similar to the Emergency Use Authorization (EUA) framework.”

I admit, I froze in horror and wrote “OMG” in the margins before I calmed down and read this part more carefully. Charitably, I think the EUA reference is really just about how the reviews of potential new products are scheduled (on a rolling basis to make the process more real-time and supposedly more efficient). I don’t think the EO is intending to use the EUA reference as a dog-whistle for a liability protection racket for industry here. But talk about tone-deaf! Between the OWS branding and the EUA shout-out, my MAHA moms are going to be calling their homeopaths for an acute PTSD remedy.

A Word for Our Friends Inside the Administration

I’m told that some people from HHS attended this Pfizer lunch. I hope it’s not true, or if it is true, that they’re using it as an opportunity to laugh this draft EO out of the room.

I have to believe that the few MAHA faithful who remain in the administration after the industry-instigated purge of the past year - Secretary Kennedy, NIH and CDC Director Jay Bhattacharya, and White House health advisor Calley Means - have not seen this document. These are people who have staked their careers and reputations on the proposition that the pharmaceutical-regulatory complex has been captured, that safety standards have been compromised by industry pressure, that the government has been de-risking pharma’s business model on the public’s dime, and that we need to fight all of that with everything we have.

This executive order is the enemy they’ve been fighting. It’s what they came to Washington to stop.

You can’t simultaneously lead a Make America Healthy Again movement and then go sign an executive order that puts pharmaceutical companies in charge of a new Operation Warp Speed designed to weaken safety and efficacy standards, mandate Medicare coverage of under-scrutinized drugs, and claim it’s all in the service of “lower costs” (LOL).

Those things can ‘t coexist, and the political base that elected this president knows it.

The Actual Answer

The draft EO closes with gestures toward lifestyle modification and AI tools for “personalized preventive guidance.”

It’s an afterthought.

The industry interests at the “intimate salon luncheon” going on right now will likely deflect attention from the four leading risk factors for preventable chronic disease - garbage food, physical inactivity, tobacco use, and excessive booze. These account for more than half of all preventable disease deaths in the United States across cancer, cardiovascular disease, chronic respiratory disease, and diabetes combined.

Folks, none of us suffers from an inborn pharmaceutical deficiency. What we suffer from is: not living like humans, for the past few generations.

Addressing these factors is hard. Much harder than turning a blind eye to unconvincing trial data and slapping an approval stamp on Pharma’s latest blockbuster. It requires taking on the food industry, the chemical industry, the seed oil lobby, the pharmaceutical companies that profit from managing the consequences of these diseases instead of preventing them. It requires telling Americans stuff that none of us wants to hear (You’re fat! Get off Diet Coke!). It requires regulators committed to protecting the public from misaligned industry interests rather than protecting industry from the public - public scrutiny, accountability and legal liability.

The cheapest disease to treat is the one that never develops in the first place. The biggest ROI is in prevention and lifestyle-mediated disease reversal, not weak-sauce symptom mitigation to manage and extend decline.

Nobody’s fooled by the pretense that this draft EO is about lowering costs for seniors and taxpayers. Throwing billions more at Pharma and transferring the R&D risk of drug development from them to us lowers nobody’s costs but Pharma’s.

The truth is that this policy is just craven regulatory capture and we have to make sure it never makes contact with the business end of President Trump’s pen.

Read more

The grace period is over. Enforcement begins now.

If that sounds obvious, it’s worth remembering that healthcare price transparency almost never happened at all.

There was a time when the idea that patients should know what medical care costs before receiving it was considered anti-capitalist, controversial, politically dangerous, and economically suspect.

I know because I was there. Here’s how it all went down.

(This story was originally published November 24, 2025)

Inside the White House War Over Ending Secret Health Care Prices

The first-hand play-by-play of how price transparency almost died in the cradle.

Price transparency is working. Not how most people expected. Better actually.

But I’ll have much more to say about that soon.

In the meantime, let me explain how it all kicked off with this price transparency business.

Back in the day, there were only a few supporters for ending secret health care prices inside the first Trump administration.

And I mean a VERY few (like count-on-one-hand few).

My first boss in the White House, and his boss, the president, were all in on price transparency.

They knew it was a bipartisan, 90 percent polling issue (that’s what we call #winning in politics). It also happened to be the right policy for reasons I’ll get to below. But, as it happens, my first boss abandoned me to become a fancy ambassador to… somewhere. Wherever. Not in the White House, having my back.

His successor, unfortunately, insisted that I convince a group of naysayers from various quarters within the building and from other agencies.

That group included a handful of free-marketeer bros with PhDs in economics, who looked pretty askance at this non-PhD, non-economist, must-be-a-lib chick. I had already earned their scorn the prior year by hand-wringing about the mid-term politics of trying to burn down the ACA.

We met weekly to discuss the academic literature about whether or not health care was the unicorn industry that would disprove the normally ironclad rule of economics: price competition lowers prices.

It felt silly — like trying to convince physicists that gravity is a thing.

Nevertheless, apparently this was controversial and the meetings dragged on, with the clock ticking loudly on the president’s term (little did we know just how short the window would be, with COVID-apalooza about to eat all other policy agendas).

I realized that something had to give, because I was outnumbered and the policy was stalling out.

Political appointees at the Department of Health and Human Services (HHS) had written a memo about why a price transparency Executive Order was crazy-talk.

Since my supportive boss left, the policy was on life support.

There was also this one study that kept coming up in the journal club and of course, in the hostile media, such as the Pharma-shilling Wall Street Journal. It was a study of the Danish cement industry — yes, Danish cement — that showed that when the government forced price transparency into the industry, prices for cement actually went up.

My allies on the Senate committee that oversees public health were so annoyed by the repeated and desperate citing of the stupid Danish cement canard that they had t-shirts made and sent one over to me, their sister in eye-rolling.

Given the aforementioned New, Less-Supportive Boss (NLSB), I knew my time was not much longer in the White House and things had to get rolling on this Executive Order. Despite the navel-gazing journal club and the WSJ industry shillery, I already knew the president loved the policy, and decided to make an end-run to get it into the State of the Union speech.

My thinking was that his word would be final and would put an end to the palace intrigue.

I managed to get a few paragraphs inserted into the draft a few days before the speech, announcing the policy, and arranged for an amazing guest to be acknowledged during the speech.

Her name was Wanda Brooks.

Wanda was a nursing home employee whose surprise $8,000 ER bill at Mary Washington Hospital in Fredericksburg, Va, had become a case study in predatory hospital billing. Wanda’s story was brought to my attention by Dr. Marty Makary (then Johns Hopkins surgeon and policy researcher and 2nd Trump term FDA Commissioner, now, regrettably, former Commissioner).

Unfortunately, the next draft of the speech that I saw had stripped all the price transparency stuff out — likely the work of the NLSB and the aforementioned economist caucus (I’m guessing, anyway).

Game on.

At that point, I put out the bat-signal for Cynthia Fisher.

Side-note about Cynthia Fisher, the zillionaire owner of Boston Beer Company, health care CEO, and fearless transparency advocate. Cynthia was the one who actually got me to take price transparency off the To-Do-At-Some-Point list and onto the Do-Right-Now list. Knowing how hard it was to get frenzied, over-scheduled staff to take a meeting, she played hard-ball. She brought my former boss, the incomparable Senator Tom Coburn, MD, then-retired but still feisty, to the party, knowing there was no way I’d be able to say no to him. When I worked for him, we had bickered like an old married couple, but the mutual affection and loyalty was unbreakable.

I spent the first half of the meeting doing what all staff always do in every meeting - I mentally rehearsed how I’d say no to the ask. The perennial problem of having way too much on our plate means we almost always say no to even the best ideas.

Then, halfway through the meeting, some switch inside my head flipped, and I said to myself: “You know this is the right thing to do. Why don’t you stop saying no and figure out how to get to a yes?”

And we were off to the races. Cynthia was and is a force of nature.

Cross her and she will bombard your email, your constituents, and the billboards in your Congressional district with compelling pro-transparency advertising, replete with Hollywood A-listers and heartbreaking stories from patients done dirty by surprise medical bills.

She never gave up — to this day — and she often seemed to have the president on speed-dial. She was FAFO before FAFO was a thing, and always with a winsome smile.

After HHS sent their price-transparency-is-stupid memo over to the White House, Cynthia found herself invited to an intimate dinner for business leaders with the president. When her turn to speak came up, she went all in on ending secret health care prices. The president, as we knew he would, loved it and told his team to get it done. Gladly! (What an amazing idea!)

So that’s why, months later, when I saw that my detailed take-down of secret health care prices and my call-out to Wanda had been stripped from the speech draft, I pulled out all the stops — Cynthia was my first call. I knew that her rolodex was more powerful than mine.

For my own part, I ran around the West Wing, cozying up to the more politically savvy types who understood the populist appeal of ending secret health care prices, like Kellyanne Conway and Mercedes Schlapp.

The speechwriters were holed up with the president, inaccessible to my harassment. So I pleaded with Derek Lyons, who wielded incredible power as Staff Secretary, possibly the littlest-known, most powerful role in the White House. The Staff Secretary’s office controls the flow of paper (including speeches) in the building and synthesizes all the edits everyone makes to that paper before it goes to the president or the public.

If Derek was persuaded, he could put his thumb on the scale in the draft.

Meanwhile, the New, Less Supportive Boss kept walking by these offices I was in (the building is much smaller than most people realize). He would do a double-take as he saw me, probably wondering what I was up to.

I waved and pretended to be casually chit-chatting.

There was no callout to Wanda and no fiery diatribe about the Health Care Swamp — but it was enough.

I knew that ONE sentence by the president of the United States would be powerful enough to move mountains, and would put an end to (at least the overt) internal opposition to price transparency going forward.

Not for nothing, a grateful nation should truly honor Cynthia for her heroic efforts, along with Dr. Marty Makary.

Marty’s book, The Price We Pay, is a classic for anyone learning the basics of health insurance and its actual impact on real people, the perverse incentives it creates and potential hacks of the corrupt system.

I sent all the naysaying political appointees around the government a copy of the book, which laid out — in the plainest English — the problems in our current insurance system — the so-called “free market” that Republicans thought existed, but didn’t.

A lot of their attitudes softened toward price transparency and the rest of the president’s populist health agenda after that.

As I had predicted, the president’s speech mention was the jet fuel the policy needed.

I eventually left the White House later that year, and to their everlasting credit, the colleagues I left behind, including the previous naysayers, were the ones who pulled price transparency over the finish line.

Policy, like politics, is a team sport.

We did it.

You’re welcome, America.

Editor’s note: This is Part 2 of a two-part series interrogating the foundational evidence behind modern virology. If you haven’t read Part 1 on viral isolation, start there. It matters for everything that follows.

Last week we established that virologists have never actually isolated a virus - they’ve just assumed the particles they see in electron micrographs are viruses and moved on.

But there’s supposed to be a safety net. Genetic sequencing.

If you can read the blueprint - the actual DNA or RNA - surely that proves what you’re looking at is real, right?

It doesn’t.

Every time there’s a new virus announced, The Authorities quickly rush to “sequence the viral genome.” After all, if the premise here is that viruses are just made out of DNA or RNA and some proteins, then it makes sense that we should be able to identify them by reading their genetic sequence - a string of nucleotides represented by A’s, G’s, C’s, and T’s (or U’s in the case of RNA).

If you weren’t impressed with the viral culture “isolation” process described last week, you might be looking for some reassurance that, at least once we have that centrifuged pellet of stuff of a certain size/density, and we’re seeing things in the electron microscope that we’re told is a virus, we can fill in some of the scientific uncertainty with genomic sequencing.

Well, brace yourself.

I wish I had better news, but the sequencing process trying to make sense of the genetic alphabet soup isn’t reassuring.

How We Got “Viral Genomes”

In 1981, a scientist named David Baltimore (who would later become famous for reasons having absolutely nothing to do with viral sequencing and everything to do with one of science’s messiest misconduct scandals), took the poliovirus, or at least the contaminated mixture of dead cells, exosomes, and genetic debris that he was calling the poliovirus, extracted fragments of genetic material, and assembled them into a computer model. The computer took all the fragments and guessed about how they might fit together if they were all one long chain. Then, Baltimore published his conclusion that the poliovirus genome was 7,440 nucleotides long.

He never proved that this sequence came from a single virus particle. He never isolated a pure virus. He just made his best guess from a contaminated mixture. And that guess became the reference genome for poliovirus.

And so in 2002, when Cello, Paul, and Wimmer reconstructed something capable of damaging cells and killing rodents using Baltimore’s published genome sequence, mail-ordered DNA, human cervical cancer cells and other cell culture sludge, many took it as confirmation that the sequence he’d found was indeed the virus. Never mind that they injected the brains of mice with this toxic cell culture sludge and genetic material we discussed in detail last week (except instead of using monkey kidney cells they used human cervical cancer cells, which I’m sure are super non-toxic and create no immune response). Also never mind that there were no control mice who received brain injections of the same sludge, but without the genetic material assumed to be the virus (whereby it might have been demonstrated that the sludge-injected controls didn’t die and therefore the only difference between the live control mice and the dead mice was the presence of the so-called virus).

Other viruses like influenza and measles followed the same process. Then, when new versions of coronavirus, like the 2002 SARS-CoV and the 2020 SARS-CoV2 virus appeared, they just used the original coronavirus reference genome, and kept building on that one.

The Game of Telephone That Never Ends

Imagine Susie is on a crappy cell phone connection with Jenny. Susie whispers a message, and the connection is cutting in and out. Based on the fragments Jenny hears, she guesses that Susie said, “THE QUICK BROWN FOX.” Jenny isn’t sure she guessed right, but she emails Betty that message. She also calls Betty - with her same crappy connection. Betty hears, “BRAVO, QUITE THE SOX.” But since Betty has the email from Jenny too, she throws out the letters that don’t match the email (the reference genome) and fills in the remaining gaps to be THE QUICK BROWN FOX. She definitely didn’t hear that message, but instead tortures what she did hear to match what she thought she should have heard. Got it?

If Jenny’s original guess about Susie’s message is wrong, everyone downstream is copying her mistake.

This goes on ad infinitum, every time someone tries to sequence the virus in what they think is the viral isolate (actually a pellet from the centrifuge of the part of the cell culture sludge that has particles all the same size and density). You can imagine with computer models and now AI, that this becomes quite algorithmic, but also, less and less tied to actual reality, as the mistakes build on themselves over and over again, in the pursuit of “consensus” with the reference genome.

That’s exactly what happened with viral genomes. Jenny (like Baltimore in 1981) made a guess from confusing material. Everyone since has just been confirming that guess by using it as a reference.

Why We Can’t Just Sequence What We See in the Electron Microscope

Now, you might be wondering, why do we have to use computer models - if we can visualize the squiggly line or spiky sphere that we’re calling a virus (because it definitely isn’t cellular debris) using the electron microscope? Why can’t we just grab that particular thing that we’re looking at and sequence its genetic material directly?

Unfortunately, this isn’t possible - the particle we see in the microscope is too tiny for our current technology to sequence. Think of it like analyzing a single grain of sand. You can see it under a microscope - it looks like quartz. But to know its exact chemical composition, you need at least a tablespoon of it to run experiments on. One grain contains too little material.

So instead, you:

1. Collect millions of grains of sand (hoping they’re all like the one you saw)

2. Throw in some debris from other sources - dirt, contamination, debris

3. Blend it all together into a pile

4. Use a reference sample of “quartz” to filter out anything that doesn’t have what looks like parts of the reference, i.e. what “shouldn’t be there”

5. Analyze what’s left over

6. Announce: “That grain is quartz!”

But you never proved the original grain was quartz. You just proved that, in a contaminated pile, you can separate something that looks like parts of your reference.

This is exactly what happens with virus sequencing:

1. Culture millions of particles from toxic sludge that are centrifuged into layers of same-sized particles.

2. Put the sludge into an electron microscope and identify a particle that you’ve decided is a virus.

3. Grab all the genetic material (fragments of fetal cow, monkey kidneys, infected sample) in one of the layers, throw the rest away.

4. Sequence the fragments in the mixture, regardless of their origin and throw the sequences into computer software.

5. In a computer model, disregard any sequences that don’t match a fragment of the reference genome for whatever virus you think you have.

6. Assemble the remaining fragments into a computer-generated long chain.

7. Announce: “Virus genome sequenced!”

You never proved those sequences came from the particle you saw in the electron micrograph. You just proved that filtering out fragments in a conglomerated mixture that do not match a reference genome produces some sequences similar to that reference.

To prove that this is just algorithmic voodoo, researchers actually studied individual cells that were supposedly “infected” with a bunch of particles of the same virus. Turns out their genomes were all different from each other. So they concluded that the reference genomes are actually more like averages of the sequences of all the genetic material sloshing around in the pellets of cell culture sludge.

When scientists announce “virus genome sequenced,” what they actually mean is:

“We took genetic material from a sick person mixed with cell culture debris. We compared it to a reference genome that was itself created from contaminated material decades ago. We kept the fragments that matched part of the reference. We discarded everything else as “contamination.” A computer assembled the fragments. We got a sequence similar to our reference.”

They call it a match to a known virus (or, if it’s not quite similar enough to a reference genome, then a “novel” virus). It’s really just a replication of a guess that was never independently verified.

The confidence with which viral genomes are presented - as definitive proof of viral existence - doesn’t match the fact that every single one ultimately rests on a foundation that was built from contaminated material, using methods that were never validated with proper controls.

And the one time researchers looked closely at what was actually in infected cells? They found a mixture of genetic material, not a single clean genome.

Which is exactly what you’d expect if the whole thing was based on a guess that nobody ever checked.

So all this doesn’t bode well for those PCR tests that told us we had COVID or not, does it?

Remember when you had to get a COVID PCR test or an antibody test (more on that in a bit) to see if you could come to work or get cleared for a surgery? PCR stands for Polymerase Chain Reaction. It’s a copy machine for genetic material.

Here’s the process: You get the brain swab with the long-ass Q-tip. That swab contains a bunch of sludge - your human cells, bacterial DNA, skin cells from your spouse that you just inhaled, whatever little fragments of those four letters in the DNA alphabet might be present. The lab extracts this mixture and puts it in a machine that repeatedly copies genetic sequences. Each cycle, the amount of target sequence ideally doubles. If there’s a lot of a certain genetic sequence, then the machine can detect it after 15-20 cycles. But if you can’t detect it after 30 or 40 cycles, it’s deemed to not be there.

Even if it is detected after many cycles, it may just be trace amounts that don’t really represent actual infection. Nonetheless, when the machine does detect these sequences matching what scientists think a coronavirus looks like - based on the voodoo reference genome we just described above - the lab still confidently reports: “Positive for COVID-19.” The problem is, we use that positive result to claim “You are infected with a virus.” These are not the same.

The test measured one thing: the presence of genetic sequences matching part of a reference.

The test did NOT measure:

• Whether those sequences came from a living virus, dead virus fragments or any other material

• Whether you actually have what we call a “viral infection”

• Whether you’re sick or completely asymptomatic

• Whether you’re contagious or non-contagious

• Whether this genetic material will harm you

• Whether you need treatment of any sort

• Anything meaningful about your health

A positive PCR test could mean any of those things. Or none of them. The test can’t tell.

Even using virology’s own terms and assumptions, you could test positive and be:

• Recovering from infection (no longer contagious, genetic debris still detectable)

• Asymptomatic but carrying live virus

• Asymptomatic with only dead virus fragments

• Not-exposed at all but your sample was contaminated in the lab or during the swab process

The test doesn’t distinguish between these scenarios.

For decades, PCR was used in labs for research - to find and copy specific genetic sequences. It worked great for that purpose, and everyone working in The Science™ understood its limitations. Then it got repurposed as a diagnostic test - to tell you if you’re “infected.” As in, do you have a disease or don’t you? But PCR doesn’t do that. It tells you: “We found genetic sequences matching our (voodoo) reference.” Those are completely different statements - one is about your health status and the other is about the alphabet that found its way into your nose.

We took a tool designed to detect genetic material and used it to make claims about infection, disease, contagiousness, and the need for quarantine or medical intervention. And then The Authorities used PCR-positive counts as “case numbers,” and the mistake gets exponentiated into decisions about population-wide lockdowns and vaccine mandates.

But wait, what about antibody testing?

Remember how we were taught in science class that people develop antibodies after they’ve been infected with a virus, and that these antibodies create “natural immunity” (that was so ignored by The Authorities)?

It turns out that the evidence that virus-specific antibodies develop in response to a given virus is based on the same cell culture “isolate” that everything else in virology is based on. So if you inject cell culture sludge that you’re calling a virus into people, how do you know exactly which proteins that you later find in their blood are the actual antibodies that their bodies created in response to this virus?

And even if you do know that, how do you know the antibodies are to the actual virus that they’ll supposedly encounter in the wild as a purified virion particle they ingest somehow? Well, it turns out that all the testing to confirm this requires “isolating” the virus, and pulling viral proteins out of the isolate, and then doing another procedure to see if some patient proteins (antibodies) bind the viral proteins, using what’s called an ELISA, a Western blot or flow cytometry.

But remember, our “isolate” (cell culture sludge pellet) hasn’t been proven to actually isolate a virus, so how do we know that the proteins we’re extracting out of it and calling “viral proteins” are in fact viral proteins? And how do we know that any proteins (antibodies) in patient blood that bind to those viral proteins are doing so because they were created after exposure to the virus in the body?

I’m not going to go down the full antibody rabbit trail - this article is about viruses, not antibodies, but hopefully you can see that these mysteries are related and that the same types of foundational experimental gaps may characterize both fields of inquiry.

Summary of Founding Myths

What virology treats as “settled science” has never been nailed down with the rigor other sciences take for granted. Physics doesn’t accept a theory because the model is elegant - it demands measurement, independent replication, and a result that holds when someone hostile tries to break it.

Virology runs on “science” that is much softer.

Every claim starts with the same toxic soup: monkey kidney cells, fetal bovine serum (cow blood), antibiotics, a culture stressed until something dies. Whatever is being claimed came from that origin.

“Isolation” in virology never means isolation from nothing. It means a particle spun out of a broth nobody fully accounts for, then a genome stitched together by software guessing how the fragments fit. It’s a model.

Nobody who claims to have seen all of the things that viruses supposedly are and do has ever confirmed it using a scientific method that avoids this house of cards.

Nobody has confirmed that little strands of genes wrapped in proteins that we call viruses aren’t just cellular debris caught by the electron microscope. Nobody has cleanly separated antibodies against the supposed virus from antibodies against the sludge - and we know the sludge alone, cow blood and all, provokes them.

Nobody has proven that the cell chaos and death (cytopathic effect) is caused by anything other than stress, toxic antibiotic exposure and starvation rather than a killer virus.

And nobody has actually sequenced genetic material after physically isolating pure viral particles, without algorithmic modeling of course. And so on.

Think about how you first ever heard the word “virus.” How did you learn what viruses are? For me it was in the context of a doctor’s office. Is the snot the right color? If not, it’s a virus. Does it respond to antibiotics? If not, it’s a virus. If you don’t know where it came from, it’s probably that you just picked up a virus.

In other words, the common knowledge about viruses is really just a catch-all incantation for when we don’t have a better answer. It’s the modern equivalent of assuming that the sound of thunder must be Thor riding wildly in the sky on his chariot.

Epilogue: But What About Contagion?

The first question arising when we realize the virus paradigm may not be as evidence-based as we’ve been led to believe is “but what about how people get sick when they’re around people with measles, chickenpox, influenza? What about the spread of HIV, or the common cold?”

In fact, during the 1918 Spanish Flu pandemic, researchers conducted an experiment most people have never heard of: they exposed healthy Navy volunteers to every imaginable transmission route from sick patients - coughing directly in their faces, blood transfusions, and injected mucus. Nothing took. Not one volunteer got sick. If contagion via viral particles is how disease spreads, this experiment should have worked to infect healthy people exposed to sick people. It didn’t.

So the question of how to explain what appears to be contagion - people getting sick together or in quick succession after contact with each other - is an important one.

Women’s menstrual cycles sometimes seem to sync up when they spend time together. Obviously, nobody thinks all the cancers that people living in Nagasaki in 1945 got were due to a “virus.” Or the many afflictions faced by the people of East Palestine, Ohio, after the train derailment caused a toxic chemical spill. The hyper-spread of gender dysphoria among teen girls in the past five years has not been postulated as a “virus” (well maybe a mind virus). Pheromones that biochemically signal attraction or other messages between animals like humans, or frequencies and resonance associated with the 6-foot electromagnetic field around the human body and its core - the heart - offer some interesting avenues to explore. In other words - people in close proximity to each other can experience similar symptoms at the same time or in quick succession for a bunch of possible reasons that don’t have to be viral contagion.

The question of apparent contagion is an important one for science to explore. I don’t know the answer - and neither do virologists. The lack of a certain answer does not mean that the viral paradigm must therefore be right. It just means that we’ve believed in Thor so long that we haven’t done the hard work of understanding exactly where the sound of thunder comes from. (Let’s explore that in a future post!)

In the meantime, one of the best questions you can ask yourself or your doctor or The Authorities is, “how do you know that the fundamental concepts you’re assuming were already proven long ago actually were?”

As I’ve mentioned before, I was gaslit in public health school about the safety profile of vaccines and the adequacy of the clinical trial design that led to the FDA licensure of these products. A lot of dogma was communicated the way all dogma is - it’s just spoken about by authority figures as if it’s a given truth, over and over until you’ve forgotten that you never asked for details.

Most Christians don’t do deep dives on apologetics exploring the philosophical proofs for God, for Jesus, the Resurrection, subsequent miracles, and so forth - but they can take comfort in the fact that some of the smartest and savviest Christians over 2,000 years have in fact kicked the tires on those fundamental questions and arrived at logical and satisfying answers. In the case of the viral paradigm, the tire-kicking hasn’t actually been done. Even the most expert virologists have been relying on an evidence base that is riddled with illogical leaps and circular reasoning.

It’s dangerous, of course, to recognize and call out that virology’s founding myths are built on shaky ground. And likely to get you branded a heretic and kicked out of the science club.

But that’s ok.

I’m more interested in reality than consensus. If that’s you too, then welcome - you’ve found a home here.

Editor’s note: This is Part 1 of a two-part series interrogating the foundational evidence behind modern virology. Part 1 covers how viruses are reportedly isolated. Part 2 covers genome sequencing, PCR testing, and viral antibody science, built on the same foundation.

I was a second class citizen in my public health school’s department of Epidemiology.

Harvard was ground zero for chronic illness research, best known for the Framingham Heart Study and the Nurses Health Study. All the cool kids were on the chronic disease epidemiology track. I wanted to study infectious disease instead. That’s why Johns Hopkins had actually been my first choice. I had signed the papers, submitted the deposit, and found an apartment in Baltimore a few months before the semester started.

But then, a funny thing happened.

I got a notice that Harvard was offering me a full ride - free tuition. Stick with me, this isn’t the humble brag it sounds like. One does not turn down free degrees from the Kremlin on the Charles, boring chronic disease specialty or not. So I got out of my lease in Baltimore, and re-directed to Boston.

A week after I got there, the financial aid office told me there’d been a mistake. A doctoral student with my same last name was the intended recipient of the money. They were bound to keep their word for my first year, but the rest of my degree would be paid by student loan (i.e. me).

God has a funny sense of humor.

Clearly, it was meant to be. It’s where I met former FDA Commissioner, Marty Makary, as I wrote about a couple weeks ago. It’s where I met the tropical health professor who recommended me for a job in South Sudan, where I realized overseas work wasn’t for me.

I had discovered epidemiology (which, before COVID, most people couldn’t pronounce, much less define) because I hated lab work.

I was pre-med in undergrad, loved studying human biology, but detested the pipettes and petri dishes in lab work. I preferred the methods of social science - statistics, graphs, p-values and regressions. It wasn’t until I was reading The Hot Zone, by Richard Preston, which was published the year I graduated from college, about an Ebola outbreak in a lab facility in Reston, VA (practically my hometown), that I ever heard the word “epidemiology.” Turns out, it combines the content of medicine with the methods of social science - a great fit. Individual patients, phooey - we treat populations!

Maybe it’s because my first introduction to public health and epidemiology was with Ebola in the Preston book, but infectious disease always seemed WAY sexier than chronic disease. Chronic disease involves the tedious and disappointing slog of changing people’s lifestyles and long-held habits, yuck!

Infectious disease - now that’s an adventure.

You get to run around in space suits, tell everybody what to do, quarantine towns, and use little hand-written tic-tac-toe crosstab charts to figure out what caused the outbreak (PS it’s always the potato salad at the church supper, at least in all the case studies).

And like legendary Dr. John Snow (no, not the Game of Thrones hottie) did when he shut down the contaminated London well responsible for spreading cholera, we infectious disease epidemiologists always had some magical intervention that would save a zillion lives and our names would live in glory evermore.

Unlike the Harvard chronic illness people, who kept getting things wrong when it came to the causes of heart disease, whether saturated fat was bad or good, and who failed year after year to get people to change their diets, exercise more, and quit smoking, while the population got sicker, fatter, more infertile and more expensive with our extinction-level chronic illness rates, infectious disease epidemiologists were able to actually, you know, end diseases, and save people. Fast. That was my take, anyway.

Now, even among the infectious disease crowd, there were the cool kids and the not-so-cool kids.

The real weirdos were the experts in rickettsial diseases or chlamydia. Then you had the middling workhorses, serious scientists focused on things that killed a gazillion people every year - respiratory disease, tuberculosis, diarrhea, malaria. But the coolest kids in school were the virus hunters. So, naturally, that’s what I wanted to be - hunting down strange new concoctions like hantavirus, Lassa fever, dengue hemorrhagic fever, you get the point. If it involves bleeding out of the eyes, I was all in.

The most pathetic virologists were those, like Dr. Fauci, who studied viruses that supposedly caused cancer or other chronic illness. I mean, the whole point of being a virus hunter was to avoid the complicated humanity of chronic illness - what a career face-plant!

Not sure if I was an adrenaline junkie or what (my later career in politics suggests as much), but I was high on the idea of being on a CDC rapid response team jetting around the globe to save people with the power of my mind or some other Dr. Snow-ish intervention.

An example was when I interned with the Carter Center on their guinea worm eradication program in South Sudan. Guinea worm is a parasite that grows into a multi-foot-long worm that slowly emerges, a little bit more each day, from the body over weeks. There is no treatment except to wrap the part of the worm that has already emerged around a little stick and then twist the stick every day a little more to try to expedite the emergence. Sometimes it comes out of nipples. Sometimes out of eyes. Usually though, less exotically, out of feet.

It burns like hell, and so people would run to the nearest water source and put their foot in the water, releasing all the parasite babies into the water, which people drink back into their system and the cycle continues. So the brilliant, Dr. Snow-ish intervention? Put a cloth filter over everyone’s water jug. Filters out the parasite babies, problem solved, disease eliminated from everywhere it was successfully implemented community-wide.

Do you see the appeal? It’s all so simple.

When we had the 101 classes in the infectious disease track, we studied the different bugs - bacteria, parasites, viruses. In the virus section, we learned what a virus was - a self-replicating piece of genetic code (DNA or RNA) and some proteins thrown in for good measure, which can enter through a cell membrane, hijack the gene-replication apparatus of the cell, replicate itself, bust open the cell membrane and travel to other cells and do the same thing. Viruses can be transmitted by bodily fluids, on objects like door handles, or in the air. There are no really great antiviral treatments that directly kill viruses the way antibiotics kill bacteria, so prevention is the best strategy. That’s it, that’s the 101. Or at least, that’s what I was taught.

You might be surprised to learn what we did NOT learn.

Namely: how these viruses were discovered, isolated, observed, cultured, and experimented upon. In other words, everything that we were taught about what viruses are and what they do was taught as a given. It wasn’t explained how The Science^TM had proven all these facts. That should have been in the 101, but it wasn’t.

I only figured that out later. A lot later. Like a few years ago later. After an entire career built around on-the-ground programs, and later, policy design and program oversight of government agencies in charge of controlling viruses such as hepatitis, HIV/AIDS, HPV, and yes, coronaviruses.

This article series is my attempt to shorten that cycle for you, so you don’t fall into the traps I did.

(Many of you already know this, even better than I do, and I’m grateful for the groundbreaking work and courage of those who have been bringing this information to light.)

This is going to be the 101 I wish someone had given me back in public health school. Because it probably would have changed a lot about what I did next.

So where did we come up with this whole virus idea in the first place?

Bacteria and parasites are living/swimming organisms that we can see under basic light microscopes. So they were understood better at the beginning of the 20th century. The problem for The Science^TM at that time was that there were some illnesses where they couldn’t find any bacteria or parasites present. So they hypothesized there might be something else. Maybe a teeny tiny other thing that didn’t yet have a name. Maybe virus?

So they started taking sludge from sick samples (sap from sick plants, snot from sick people, etc) and pushing them through filters to try to filter out the bigger bacteria/parasites and see if what got through the filter still seemed to cause illness in previously healthy organisms. The problem? The mode of transmitting to healthy samples was pretty damaging in and of itself. There was mechanical injury in the transfer. Also, there weren’t always controls (healthy samples receiving the same toxic sludge EXCEPT the sick organism’s fluid), and when there were, often the controls would experience some or all of the same symptoms as the “infected” samples.

These experiments never disproved the virus theory outright (though some came close). But neither did they prove it. They only demonstrated that something was making the healthy samples sick after “inoculating” them with the sick organism’s fluid. But even that wasn’t entirely clear. The problem is that, in many experiments during the first half of the 20th century, including pivotal ones by John Enders, and Bech and von Magnus, the controls got sick too.

In the Spanish flu pandemic around 1917, researchers tried everything to make healthy volunteers sick by having sick people coughing on, shaking hands with, spraying lung gook in the faces of, transfusing the blood into, and injecting sputum into the volunteers - to no avail. Weirdly, mainstream virology and news reports often selectively leave these confusing facts out and students are never taught it.

In any case, something other than identifiable bacteria or parasites can make healthy organisms sick in some experiments, but the something isn’t always identified well. In the case of the virus experiments, it could be the toxic crap in the base exposure of both the “inoculated” and the controls, and not something specific to the sick organism. The facts on this vary by the details of each experiment, which we’ll discuss further below.

The early researchers acknowledged that they didn’t know what this smaller “agent” or “exposure” was, but they called it “virus,” the latin root of which simply means toxin or toxic fluid. Quite a big distance between that and the specific, self-replicating DNA/RNA+protein definition that we are taught today.

So How are Viruses Isolated?

Virology has not advanced much more than the seminal “isolation” experiments by John Enders and Bech and von Magnus in the 1950s.

Here are the steps that we still use today:

• A sample is collected from a sick person - typically a nasal swab, blood, or throat washing. This material contains everything present in that person’s body at that site: dead cells, cellular debris, bacteria, fungi, exosomes, proteins, and whatever else is there. It is not purified or filtered at this stage.

• Antimicrobials - typically penicillin, streptomycin, and often amphotericin B - are added to the sample in large doses to kill bacteria and fungi. These antibiotics and antifungals are themselves cytotoxic (especially to kidney cells), meaning they are toxic to cells at the concentrations used.

• The sample is now added to a cell culture - usually a line of monkey kidney cells (Vero cells are the current standard, derived from African green monkey kidneys), grown in an artificial nutrient medium. These cells are already stressed by definition: they have been removed from their natural environment, grown on plastic, fed an artificial mixture of nutrients, and kept alive under conditions nothing like those inside a living body.

• The nutrient medium (the food for the cells) is fetal bovine serum (FBS) or in layman’s terms - fetal cow blood. FBS is harvested by stabbing a live cow fetus in the heart with a large-bore needle, after the mother is slaughtered (you can imagine the stress/cortisol/hormone profile of the living fetus at that point). FBS is used because it contains a complex mixture of growth factors, hormones, and proteins that keep the cells alive in their artificial environment. Without it, the monkey kidney cells would automatically begin to die. FBS is not a defined, standardized substance - its composition varies batch to batch and contains unknown quantities of baby cow proteins, lipids, growth factors, and critically, cow genetic material and any contaminants in the blood of the baby cow.

• At the same time that the sick sample (the snot, blood or other fluid from the sick person) is added to this cell culture being kept alive in a very artificial environment by fetal cow blood, the researchers simultaneously attempt to take away as much of the fetal cow blood as they can. This is because it’s thought that the FBS interferes with the virus’ ability to penetrate the monkey kidney cells. The problem is that the hour or two without food intensely stresses those cells, which were already on the verge of death. They begin to show signs of breaking apart and deterioration that is later attributed to the virus. So at that most important moment - when the supposedly virus-infected patient sample is introduced to the cells, they are already freaking out.

• After about 1-2 hours of absolute starvation, a little bit of FBS is added back - but between 10-20% of the amount it was before it was initially withdrawn. So now the cells have just spent 1-2 hours in total starvation, and then they’re given enough food to merely be mostly starving.

• When the cells show the predictable and inevitable signs of chaos and death, this is called cytopathic effect (CPE), and is attributed solely to the presence of the virus. I’m not kidding.

• But just because the virus is presumed to be present in the sludge doesn’t mean that it’s been isolated, that is, separated or purified out of the sludge.

• So then they take the sludge of dead and dying, poisoned (with antimicrobials), starved and environmentally stressed cells, and they throw it in a centrifuge. This separates out all the different ingredients in the sludge into layers of pellets based on size/density. But there can be tons of different things in the pellets containing similarly-sized particles.

• Then they take a certain pellet - the one that is the size that the virologists already “know” is the size of the virus they’re trying to isolate (see how circular that is?) - and they throw it under an electron microscope (because a regular light microscope can’t see stuff as small as a virus is alleged to be).

• When they identify some debris or other particle that seems to be present in some high quantity, they call it the virus. And the first guy to characterize some particular shape gets the right to name the virus and the disease that supposedly is caused by it in the patient from whom the snot, blood or whatever was taken. Then that shape becomes the “standard” way of identifying that virus later, so that when virologists are isolating viruses that they already “know” about, then they just look for the particles that match the shape that some researcher once called the virus. The squiggly snake is Ebola, the spiked ball is coronavirus (if the spikes are numerous), or influenza (fewer spikes), or HIV (same size but slightly fewer spikes) - get it? They’re TOTALLY different, for realz.

• The tricky thing here of course is that the debris from dying cells, such as exosomes, as well as artifacts that are known to appear in electron microscope visualizations are also similar-looking.

So, you might be saying to yourself: “Self, I have questions about this process.”

Yeah, you wouldn’t be the only one.

In fact, a few years ago, the German virologist Stefan Lanka decided to call bullshit on this process, and he made a public promise to pay 100,000 Euros to anyone who could provide scientific evidence that measles is caused by a virus, specifically by publishing a single paper that:

• Proved the existence of a measles virus

• Showed its diameter

• Showed its genetic information (more on that next week)

• Showed that it caused measles.

A German physician named David Bardens submitted six papers collectively purporting to satisfy the criteria. Lanka wasn’t convinced and he didn’t pay. Bardens sued.

A lower court found for Dr. Bardens and ordered Lanka to pay up. But Lanka appealed. And at the appeal, the court commissioned expert testimony from an independent virologist who largely supported Lanka’s criticism of the “isolation” methodology. Lanka prevailed.

The court held there had been no definitive proof presented.

Mainstream reports didn’t correct their earlier headlines about Lanka having lost and been disgraced. Of course they didn’t.

Meanwhile, Lanka conducted his own experiments to replicate the Enders isolation procedure - but this time without any “viral” sample from a sick patient. He worked with a contract laboratory to perform the procedure described above exactly, but without the supposed virus present. His published paper reported the same finding as Bech and von Magnus - the same cytopathic effect occurred in the uninfected monkey kidney cells - which supports the idea that it’s the toxic sludge, starvation, stress and environment that is killing the cells, not a virus.

Final thoughts with that in mind.

I spent an entire career working to control epidemics caused by viruses, those tiny microbes I was never taught to question, and without a foundational understanding of how viruses are actually proven to exist: a centrifuged slurry of snot, monkey kidneys, antimicrobials, fetal cow blood, and a cell starvation protocol enshrined as gospel.

Followed by seventy years of The Science ™ stacked on top of this weird theory, with nobody asking what actually proves the foundation.

I’m not saying viruses don’t exist.

I’m saying I don’t know what we’ve isolated (if anything) - and neither does anyone who learned what I learned, the way I learned it, if they’re being honest about it. I’m embarrassed for my profession and every virologist who spends their days doing this sludge-technique over and over again and calling it “isolation.”

So that’s the viral isolation problem. But isolation is only the first of many questions.

Next week we go down the genome sequencing rabbit hole. Spoiler alert: it doesn’t get better.

Note to paid subscribers: there are many physicians, scientists and other experts whose work has schooled me on this subject in recent years. If you’d like a technical deep-dive to check my homework on this, I recommend the short book by Dr. Mark Bailey - just DM me and I’ll send you the public link to the free version of his book, Farewell to Virology.

In April 2020, you couldn’t go to church, but you could go to Walmart. (Apparently viruses travel 6 feet in some places, but not others.)

Then the FDA approved a vaccine label for a product that wasn’t even available, while extending emergency authorization for the one being injected into arms. Humm.

None of it made any sense, and I found myself asking the same question on repeat - Why?

The answer wasn’t complicated, but it was one I hadn’t been trained to see. I had to figure things out on my own like so many others.

The people best positioned to see what was actually happening were the ones who were never inside the status quo framework to begin with. People like who’d been in the game for decades.

I sat down with him last week to talk about what happens when regulators stop protecting the public and start protecting the industry - and why the people running circles around establishment thinkers during COVID were the ones we’ve all been told to ignore.

Watch Katy on RSB Show Here

*****Fair warning: this one isn’t about your health (well, it’s about the health of the Republic, so perhaps that counts…). Jason and I worked together in the U.S. Senate, and what happened last week was too unhinged to leave unremarked. More health and health policy next week - PROMISE! - Katy*****

Last week’s collective freakout over the recently announced Anti-Weaponization Fund illustrates how divorced from reality partisan politics has become in the DC bubble.

As professionals who spent most of our careers advising legislators and leading oversight investigations in the U.S. Senate, it was bizarre and perplexing to watch this unhinged, uninformed bipartisan hysteria drive GOP leadership to send everyone home rather than quell the Republican bed-wetting and beat back the Democrat nonsense.

This is the biggest fracas over nothing that we’ve seen in a long time, and that’s saying something. If you’re interested in understanding what actually happened, here’s an explainer.

First, some context Congress would rather you forget

When it comes to enforcing immigration law, Congress has refused to fund certain segments of the federal government (ICE and Border Patrol). Those agencies have thus been living off a surplus from last year’s One Big Beautiful Bill, affectionately called the Big Beauty, rather than their normal annual appropriations.

When it comes to funding the Justice Department’s ability to settle any legal claim for any amount of money, Congress long ago put that on autopilot, using what’s called a “permanent, indefinite appropriation”- in other words, an unending supply of blank checks. It started like most government programs do, as something a little less crazy.

The Judgment Fund, as originally designed in 1956, was meant to allow the Department of Justice (DOJ) to pay damages of less than $100,000 when ordered by a court - without having to seek budget authority from Congress each time. So, at first, it was an unending supply of blank checks – but only up to $100,000 each. Makes sense, right? Why require an act of Congress every time a court orders the government to pay damages to a citizen it has wronged?

But in 1961, Congress amended the law to let DOJ use the Judgment Fund for more than just paying judgments. It granted authority to also pay for settlement agreements in pending, or even potential legal cases. The $100,000 cap still applied, though. It didn’t get really bonkers until 1977, when Congress eliminated the cap altogether – unlimited bonanza!

Administrations of both parties have tapped the Judgment Fund routinely since then, mostly for legitimate purposes to avoid or cut short costly litigation and remedy government wrongdoing (there’s been plenty to remedy).

The Fund was the logical necessity of a regulatory state run amok - extending its tentacles further into our daily lives every year, with the brute force, incompetence, and injustice that too often accompanies government action. Naturally, there would be citizen victims - those whose lives, livelihoods, and reputations were damaged by government malfeasance. When they understandably sought redress by suing the federal government, of course it’s DOJ serving as the government’s lawyers. As such, DOJ had to decide whether to settle the case by paying damages or go to court, where the government could lose, or be subject to, shall we say, an awkward discovery process.

However necessary the authority to settle cases may be, without any guardrails or upper limits other than the “good judgment” of government bureaucrats pressured by politically-appointed leadership, it will also naturally become subject to abuse and controversy without oversight.

Enter: The 1776 Fund™

Fast-forward to last week. The Senate got its knickers in a twist and fled town over an “unprecedented slush fund” - supposedly created by settling the case President Trump filed against the IRS for illegally leaking his tax returns along with the confidential returns of thousands of other citizens’ to ProPublica and The New York Times.

Unprecedented, they said - except it was Congress itself that created the mother of all slush funds.

Through the Judgment Fund (and the removal of the cap), Congress is to blame for giving DOJ unlimited spending authority in the first place - long before anyone had ever heard of the Trump-IRS settlement.

On the surface, the terms of the settlement require a formal apology and authorize the creation of an “Anti-Weaponization Fund” at DOJ. No dollar amount is specified in the agreement, but DOJ later announced it was carving out $1.776 billion (get it?) from the Judgment Fund to pay claims of damages from the abuse of government power to target political enemies through lawfare and weaponization. The 1776 Fund™ does have a better ring to it than “Anti-Weaponization,” so that’s what we’ll call it.

But don’t be fooled, this is all smoke and mirrors. The Judgment Fund itself has no cap. It’s a permanent appropriation - meaning it’s automatically funded, no annual Congressional funding vote required. So this isn’t some brand-new “slush fund.” It’s simply DOJ using the already-unlimited blank check authority Congress surrendered half a century ago. It’s the same unlimited money with a different label on part of it.

In other words, this is nothing more than a marketing tactic.

The 1776 Fund™ is just a public invitation for victims of political weaponization to sue (or threaten to sue) and settle with the Federal government. The announcement was nothing more than a DOJ press release.

To punctuate the earlier point: DOJ already had all the statutory authority it needed to remedy what the settlement calls “misuse of government power for improper political, personal, or ideological reasons” without carving out a special sub-account in the Judgment Fund. And if there were ever a misuse of government power for ideological reasons, illegally stealing and leaking thousands of Americans’ tax returns in an effort to embarrass the most prominent of those Americans, Donald Trump, certainly qualifies.

The Biden DOJ let the supposed lone criminal leaker, Charles Littlejohn, off with a slap on the wrist, allowing him to plead guilty to just a single count of unauthorized disclosure of tax returns, even though he admitted to stealing and leaking thousands of them. Isn’t that convenient? No messy trial that might risk exposure of more senior government bureaucratic negligence or complicity. And no remedy for the victims.

Whatever damages you think might be appropriate in this or similar cases, nearly 50 years before the Trump-IRS “settlement,” Congress had already removed monetary limits on DOJ’s settlement authority. The $1.776 billion number makes for cute marketing, but wasn’t actually specified in the settlement agreement itself and, of course, DOJ could have carved out any amount imaginable from the literally infinite pot of money Congress authorized.

The only brake on the process under current law is that settlement payouts from the Fund must only be for controversies that could have been litigated and could have resulted in a payable judgment. Since The 1776 Fund™ is simply a logo slapped on a portion of the Judgment Fund, that means it is also subject to these minimal requirements needed to tap the Judgment Fund - it’s not like DOJ can just start handing out checks like Oprah handing out cars to her audience.

Nevertheless, this is far from the first time that use of the Judgment Fund has seemed dubious to outside observers, though the real innovators here were Presidents Obama and Biden.

For example, in 2010 the DOJ Civil Rights Division tapped the Judgment Fund for $680 million to settle a single class-action discrimination lawsuit broadly alleging bias in farm loan programs from 1981–1999. The Obama administration set aside that pot of money to compensate victims, but when no more victims could be found, it still had more than $300 million to play with. So, rather than returning the money to the Treasury, it sent the leftover funds to politically aligned nonprofits that had filed no claims. Critics said the total funds far exceeded the real “litigation value” of any potential claims, but were distributed anyway.

Also brought to you by The Judgment Fund, Peter Strzok ($1.2 million), Lisa Page ($800,000), and Andrew McCabe ($700,000+), 3 senior FBI officials publicly exposed for chicanery that included leaking to the press and trying to impact the 2016 election. They later filed claims alleging violation of their privacy and wrongful termination, which the Biden DOJ settled and paid.

So, nothing about the current controversy is new or unprecedented. Unfortunately, neither side has enough incentive, self-awareness, or understanding to tell you the truth: this whole brouhaha is a nothing-burger.

Democrats howl that The 1776 Fund™ means there is a massive new pile of your money that the Trump administration has stolen through a corrupt, illegal and unconstitutional bargain in order to reward violent January 6^th insurgents - the game of “Demagogue It” that regular readers will recognize.

Because the legacy media can still amplify that message often and loudly, some weak-kneed or shockingly uninformed GOP Senators may even believe it’s true. And, no doubt some hard core MAGA-faithful will want to brag that it’s a brilliant 4-D chess move Trump invented to own the libs so hard you’ll be tired of winning.

It’s neither.

Far from a new or unique form of cronyism-by-settlement, it’s just DOJ announcing an intent to keep using those blank checks Congress handed out to settle whatever claims it wants to pay. According to the announcement, the Acting Attorney General will delegate this pre-existing authority to five other people who will sort through the merits of each case. But that delegation could have occurred before the Trump-IRS “settlement” and relies on zero new authority from that agreement.

One of us (Foster) has direct experience with DOJ’s statutory authority to pay damages to remedy political weaponization, having founded a nonprofit representing whistleblower clients who settled claims during both the Biden and Trump administrations. That organization, Empower Oversight, has negotiated settlements for clients, including non-political career government employees with personal beliefs across the political spectrum - including Democrats, Republicans and Independents. These clients were targeted for their beliefs or for objecting to the targeting of others. Most of their ordeals began after they sought religious exemptions from the COVID-19 vaccine mandate or after they made legally protected whistleblower disclosures about politics improperly affecting law enforcement decisions.

Even though these settlements occurred quite publicly between June 2024 and August 2025, House Judiciary Democrats waited until just before The 1776 Fund™ announcement to suddenly “launch an investigation” into rumors about it, lying about Empower Oversight’s clients as well as complaining about other settlements entered before the announcement, including with former National Security Advisor Michael Flynn and former Trump campaign advisor Carter Page.

Ironically, that illustrates our point.

Settlements already can and do happen routinely with the blank checks Congress handed over 50 years ago. The 1776 Fund™ doesn’t change that. Controversial settlements have occurred before and will continue to occur under administrations of both parties unless and until Congress amends its permanent and indefinite appropriation to the Judgment Fund to restore some limits on how it can be used.

Which brings us back to what happened last week

Instead of looking in the mirror and taking responsibility for what it has done, Congress freaked out and the Senate left town - another episode in the Senate’s ongoing insistence on doing nothing. By “insistence,” we mean an obsessive, compulsive, pathological, and scandalous commitment to doing nothing.

For those of you fortunate enough to live outside the Beltway and its psychosis, let’s bring you up to speed as to where things stand procedurally.

Congress was on track to appropriate funding for ICE and CBP, as well as some Secret Service security beef-ups. (It’s not like anyone has tried to kill the president, right?) Also included were some DOJ-related immigration court and counterterrorism efforts - all as part of a “skinny” reconciliation package. Regular readers will recall previous posts complaining that a “skinny” bill was a grotesque waste of an opportunity to address the affordability crisis prioritized by voters, such as with health care reform or other issues like housing and energy costs.

Reconciliation is a type of bill, designed to be part of the budget process, that allows for certain fiscal measures to be moved in the Senate under privilege, with only 51 votes rather than the usual process that requires 60 votes to end debate and move to final vote (aka the “filibuster”). The majority party of either stripe will frequently use reconciliation to get through legislation that doesn’t have bipartisan support, such as Obamacare, or the “Big Beauty.”

But of course, Congress is so dysfunctional these days that even their most basic job - funding the various departments of the executive branch - has turned into a hyper-partisan affair. The shutdown showdown earlier this year was eventually overcome (well into the fiscal year to which the funding was supposed to apply, sigh), except for one unresolved dispute: ICE and CBP.

Democrats have refused to fund these agencies and pay those federal workers, in order to spite the president over his deployment of ICE and Border Patrol agents to enforce the law. In case you’ve forgotten Schoolhouse Rock, those laws are passed by Congress.

In any case, now that we are already nine months into the fiscal year in question, the Congress finally had a plan to fund the agencies. The reconciliation bill was on track for a vote in the Senate, imminently. And then the DOJ made its seemingly unrelated announcement about the Trump-IRS “settlement” and The 1776 Fund™.

Cue the Senate’s nuclear meltdown

If you read the legacy press, you’ll hear melodramatic accounts of Republican freakout in closed session with Acting Attorney General Todd Blanche, summoned to explain this crime against humanity.

Apparently, Republican Senators are so aggrieved about this policy that Majority Leader Thune has suspended consideration of the reconciliation bill funding ICE and CBP and sent his colleagues home for the week.

What, you might ask, does The 1776 Fund™, whatever its merits, have to do with paying the salaries of ICE agents and CBP officers who risk their lives to enforce the laws passed by Congress?

Nothing. Sort of.

We say “sort of” because Democrats are using the opportunity of the reconciliation bill as a moving vehicle to amend it to exclude anyone with a claim related to January 6th from eligibility for any settlements. Some weak-kneed Republicans could help the Democrats to derail the entire funding bill over this political sideshow. This is the vote that some Republicans are so afraid of that they fled the city just to avoid it.

Why are they so afraid?

The political dilemma is supposedly that Republicans who vote no would be painted as supportive of “violent J6 insurrectionists”- not a good look in some swingier states. Republicans who vote yes would be bucking the president, and could be painted as weak on fighting the Democrats’ lawfare - politically risky in redder states, where voters were rightly (in our view) alarmed by the Biden administration’s unprecedented use of DOJ to persecute Biden’s political enemies while protecting his family and political allies.

On the one hand, it is understandable that Senators might be annoyed at the White House for putting them in that position by announcing The 1776 Fund™ just prior to the vote.

On the other hand, life is “nasty, brutish, and short.” We all have to pay taxes (except Hunter Biden, apparently), and most Americans expect their Senators to take a tough vote once in a while, especially if it’s necessary to keep paying those in law enforcement who risk everything to keep us safe. On this one, you can count us in this latter camp.

But that’s actually not why this whole kerfuffle is legislative and political malpractice.

We are, of course, cognizant of the stereotype of crusty Senate veterans sneering down our noses at the “kids today” making a mockery of the very important work we once loved. But last week, we asked each other, “wait, are we the only ones who see the obvious?”

As we’ve explained, the 1776 Fund™ is just a White House branding exercise on a power Congress handed over decades ago.

So, why is Congress shocked? The Judgment Fund is their program - their decision, supported by all of them for decades. And why are some GOP Senators so afraid of the Democrats’ and their media allies’ dishonest framing that they ran away rather than stand and fight back with facts?

Aggrieved Senators would argue (and ARE arguing) that DOJ didn’t have to wave the blood-red J6 flag in front of Democrats right before the reconciliation bill was up for a vote, taunting them into filing amendments that would prohibit their J6 boogeymen from getting access to the Judgment Fund through the newly announced carve-out fund.

But the talking points and strategies to beat back such an amendment are not that hard.

No matter your views on J6, certain core, neutral principles remain the same. The Judgment Fund was established precisely to compensate people who were harmed by government overreach. Someone has to decide whether to litigate or settle each individual claim on the merits, and Congress cannot do that. That is an Executive Branch function. Congress can, however, write into law basic guardrails to govern the process, and maybe it should. But is a budget reconciliation bill the proper way to do that? Or should there be committee hearings, study, and deliberation on exactly how to write thoughtful rules that place reasonable limits on how DOJ exercises this authority?

This is precisely the sort of talking point that should resonate with the Susan Collinses and the Thom Tillises of the world and which they could adopt in this case, to justify opposing a Democrat amendment aimed at killing what’s really an immigration spending bill.

The Byrd rule in the Senate reconciliation process requires amendments to be primarily fiscal in effect rather than policy-oriented. Serious reform of the Judgment Fund might be a good idea, but that’s definitively a policy-oriented legislative task, not just a funding measure. But if a Democrat amendment miraculously survived the Byrd rule (or the 60-vote point of order to waive such a rule), then two can play this game.

Republicans could force Democrats to vote against some of their own sacred cows.

This happens all the time as a tactic to get the original amendment withdrawn. GOP Senators could file a separate amendment similar to the Democrat one being contemplated to prohibit certain people from receiving settlement payments.

For example, GOP amendments could describe categories designed to block settlements for a long parade of partisans who might line-up for payouts from a future Democrat Attorney General - including such supposed “victims” as Hunter Biden, James Comey, Dr. Tony Fauci and his deputy David Morens, John Brennan, John Kerry (remember those retaliatory Logan Act violations?), and Federal Reserve Governor (and alleged mortgage fraudster) Lisa Cook.

Categories could include foreign pro-Hamas activists targeting Jewish students, officials in sanctuary cities who defy federal law, and activists who obstructed, violently resisted, or threatened ICE agents conducting lawful enforcement operations.

Any number of amendments could be drafted to illustrate the folly of placing politically targeted limits on the government’s ability to settle legal claims. We’re old enough to remember when, instead of crying and refusing to take painful votes, some in the GOP Senate (including Senate legends we worked for like Tom Coburn and Chuck Grassley) would fight back.

You want to politicize the Judgment Fund? Game on.

Let’s show you how ugly that could get. Then maybe cooler heads will prevail, and we can talk later about serious Judgment Fund reform that reasonable people on both sides could support, such as monetary caps and enhanced oversight.

In other words, there is no cause for hysterics, shutting down the Senate floor, burning down the budget process, or blocking funding for immigration enforcement and security beef-ups over this big fat nothing-burger.

Memo to the Senate: stop the madness and get back to work.

Paid subscribers get access to the actual document we’re putting in the hands of congressional staffers right now. It gets a little technical - statutory frameworks, certification requirements, the works. If you want to understand why the Congressional freakout is unwarranted as a legal matter, it’s all in there.

• Congressional staffers or members of Congress interested in this document, DM us with your government email and we’ll send it to you for free.

• Paid subscribers who want a copy, comment below or send a DM to and we’ll send it over.

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That’s actually the business model. I know because I spent two decades trying to fix it. Worst of all I had to sit on the sidelines and watch it completely fail my sister.

Ray Kober had me on The Broken Healthcare Podcast to discuss what’s happening. Here’s what came up:

→ How a Mormon-turned-Catholic-turned-actual-nun ends up running health policy in the Trump White House (yes, real convent, two years).

→ How I watched my betters negotiate with warlords in South Sudan in my twenties, and why that turned out to be excellent training for negotiating with PBMs in my forties.

→ Why the fight is no longer Republicans vs. Democrats, but actually the healthcare swamp vs. the rest of us, and how for the first time in my career, the swamp is starting to lose.

→ Why the free market hasn’t failed in American healthcare. It’s actually never been tried.

→ The new federal law that just put every middleman in the country on personal notice, and why nobody in Washington is talking about it yet.

→ My sister’s hospital that did everything “by protocol” and nothing that actually helped her. And the day I decided I was never going to be a patient in this country again.

If you’ve already figured out that something is very wrong with our health system, please listen in.

You’re not crazy. You’re just early.

My group of grad-school pals, forged in the decrepit (but cheap!) Harvard medical campus dorm in the mid-1990s had a running joke about our friend Marty. Whenever someone noticed he wasn’t with us, we’d surmise that, while we were goofing off or decompressing, he was cranking out another peer-reviewed research paper.

We marveled at how he somehow found countless hours the rest of us couldn’t, cozying up to the faculty’s brightest lights and figuring out a research question aligned with their interests. He knew no journal would publish a study authored only by a student, so he would network with these researchers, learn from them, and collaborate on an interesting project. The rest of us were just trying to figure out logistic regression or the Krebs cycle, and we good-naturedly ribbed him for being an over-achiever that was making us all look bad.

By the late 1990s, Marty and I were in our first post-graduate jobs - both having landed at Georgetown University in DC - he was in his surgical residency, I was on the research faculty. We were so poor in those days, and I could always count on Marty to let me know where we could score free food at some Pharma-funded reception on campus. Probably the last time either of us benefited from Pharma influence-peddling.

Over the years, our careers were different but we ran in the same church circles in the city and stayed friends as our professional paths overlapped more and more. He wrote his first book, Unaccountable, about his ridiculous experiences during residency, which placed him squarely at odds with the broken status quo of Big Hospital’s underbelly. That book, published in 2012, was eventually adapted to become the TV show, The Resident (with Manish Dayal playing the Marty-type character).

Continuing in that vein of calling out corrupt systems, Marty’s research interests at Johns Hopkins started to intersect more with my professional interests as well. By then, he had settled down as a pancreatic surgeon and public health professor, and I had left full-time epidemiology for the Senate staff. His work involved developing the patient safety checklist in the OR (so you don’t operate on the wrong knee or leave a surgical instrument in the patient’s belly - yup, that happens). He had a knack for attracting the smartest people to work with him on his research, like health care quality guru Christi Walsh, CRNP, the most prolific health financing expert Dr. Ge Bai, PhD, and applied health quality business leader Dr. Will Bruhn, MD.

It was Marty who first turned me on to the absolute degeneracy of the Health Care Swamp. While I was still spouting Republican talking points about how we have to protect the “free market” in health care (editor’s note: health care is neither free nor a market), he was exposing just how failed and distorted that market was. He was publishing on how doctors in different specialties were reimbursed for the volume of their procedures, not the quality of their care, at great cost and risk to patients. He and his team convened groups of expert physicians in every specialty and facilitated their development of a new type of quality metric, asking them to agree on the most indefensible types of overtreatment in their specialty and then using Medicare data to provide every doctor in that specialty his or her rate of that overtreatment. This idea morphed into his team’s creation of a powerful set of “appropriateness” measures that are now used across the country (including in my business helping employers steer their workers to high quality care).

Around this same time, Marty co-wrote a book, Mama Maggie, about his Aunt Maggie Gobran, the Egyptian Coptic Christian humanitarian and Nobel Peace Prize nominee known as Cairo’s Mother Teresa. I suspect that her example of unconditional love for the forgotten children of the Cairo garbage slums helped form Marty’s acute sense of justice. There is often a sort of simmering anger just under the surface when he talks about those who would exploit the weak. Indeed, vulnerable populations became the focus of much of his research, and a theme he wrote about in his books.

Fast-forward to 2018 or so, I was working in the Trump White House and joined Marty and his colleagues at a courthouse in Fredericksburg, Virginia. I was alarmed to discover that, every other Friday of the month, the courtroom docket was reserved exclusively for lawsuits being brought by the local academic medical center, tax-exempt Mary Washington Health, against their own patients who couldn’t afford to pay their medical bills. On this day, like all such Fridays, Marty and his team would stand at the door and intercept the defendants as they filed in. These were working class people, often showing up in their job uniform, embarrassed, not knowing what to expect but grim-faced with the recognition that they were in deep trouble.

Marty offered to serve each one as a medical expert on their case, reviewing their bills and offering to testify on their behalf - if, as was almost always the case, the bill was unfair or predatory, riddled with upcoding, inappropriate care, and other contradictions. The team included a local lawyer, the young whipper-snapper Joey Kirchgessner, who would argue the case until the hospital cried uncle. They helped a lot of people every time they were there. I was so proud of Marty and felt honored to be with the team that day.

Not too long after that, Marty was finishing up his next book, The Price We Pay, about the predatory practices of the health care industry that exploit the poor and sick in our country.

This problem had my full attention, because I was drafting an executive order on ending secret health care prices. So naturally, it was Marty I called to kick the tires on ideas and help me think through the issue. Later, when the draft order was circulated around the White House and HHS, and was facing internal resistance, I sent Marty’s book to about a dozen key officials and insisted (begged) forcefully that they read it. I might have been imagining it, but their objections seemed to take a less strident tone as they read story after story of ways that the ordinary incentives created by the health care system produced extraordinary harm for everyday people.

When I left government, I looked around at the apocalyptic health care system and despaired at the idea of having anything to do with the corrupt industries fleecing the American people. Most people with my resume end up shilling for this or that special interest from Big Pharma to Big Hospital, helping them lobby to keep the taxpayer gravy train rolling. I just couldn’t do it.

It was Marty who told me about a remarkable organization called Health Rosetta, a growing tribe of insurgent, honest benefits advisors helping employers fire the big carriers and PBMs and build re-humanized health plans. These advisors - whose business model was differentiated on radical transparency and independence from the usual conflicts of interest that ruined the rest of the industry - were the only bright light that I could see in the health care landscape. They took me under their wing, and the most generous among them mentored me as I built my business on Health Rosetta principles.

Marty and I occasionally edited each other’s writing or speeches, and collaborated on academic papers here and there. When I was invited to give a keynote somewhere, he mercilessly mocked my slides: “nobody wants to read your bulleted notes to yourself on a slide. Use pictures only.” My speechifying has improved significantly since.

When he was nominated for FDA Commissioner, I gave him a warning as serious as a heart attack: “You’d better get right with God, buddy, because you’ll be taking on the most demonic, most powerful industry on earth.”

I meant it.

I reminded him that my friend and colleague Daniel Best, the first-term HHS official in charge of developing the president’s plan to lower drug prices - a plan that the pharmaceutical industry despised - mysteriously fell to his death off a balcony. It was ruled a suicide. He had a wife and young kids and no apparent sign of depression. There was shell-shocked chatter about how none of us had seen it coming, but maybe that’s because it hadn’t been coming. Everyone around me seemed to accept the approved narrative, for reasons I never understood.

Although the forces allied against reform of FDA-regulated industries are first and foremost spiritual - early in the process, Marty faced more earthly obstacles. As he tried to assemble a team during the presidential transition period and during the pre-confirmation process, he struggled with how the personnel vetting system made it next to impossible to recruit qualified people who didn’t have demonstrated Republican or Trumpian bona fides - even though many people who make their careers outside of politics do so successfully only by keeping their political loyalties on the down-low.

There is another structural flaw in staffing up to execute the MAHA agenda:

• There are the MAHA experts - activists, scientists, researchers and practitioners who have been toiling in the MAHA vineyard of the Lord for decades.

• And there are skilled and experienced government operators, who know how to drive an agenda through the deep state bureaucracy, industry opposition, Congressional bed-wetting and White House political hackery.

These two circles on the Venn diagram do not overlap.

The president learned the hard way in his first term the importance of having loyal people in office, who can beat back the deep state and drive his agenda. So it’s understandable that the Presidential Personnel Office (PPO) - the White House unit responsible for vetting and recruiting the 4,000 or so political appointees placed throughout the administration to serve at the president’s pleasure - would prioritize MAGA or at least traditional Republican street cred over almost anything else.

But traditional Republicans often didn’t have any sort of MAHA street creds. And to make matters worse, the hiring process at the beginning of the second term strangely excluded many first-term Trump appointees - loyal soldiers who had stayed through COVID, through the election chaos, through January 6th, and turned the lights off on Jan 20th, 2021. I can’t tell you how many friends and former colleagues who wanted to return (I liked my life too much to join them!) - experienced operatives and MAHA friendly, absolutely loyal to the president - who found themselves on some blacklist for some reason. Many of them were never hired. Some only found their way in after heroic efforts, many months after the Inauguration. I don’t know about other agencies, but I do know that this problem was especially acute at HHS, and as a result, there has been a massive vacuum in the department’s policy operation - lacking the skilled policy experts to drive the MAHA agenda, surrounding the agency heads like the Secretary, Marty and NIH Director Dr Jay. Bhattacharya.

Almost every advisor or deputy Marty wanted was rejected by this political machine. Worse, lawyers at HHS schemed and undermined him from the beginning. They, as well as the pharmaceutical industry and a particular social media influencer who can get the president’s attention (and who I suspect was paid by a certain drug company), went after his most trusted deputy, the incomparable Dr. Vinay Prasad MD. Dr. Prasad was widely respected for being a take-no-prisoners expert on how most studies utterly fail to answer the questions they intend to, and how medical practice guidelines can go deeply off the rails as a result. Of course, when he started bringing this much-needed bullshit-meter to the FDA, they naturally ran him out of town.

Other deputies and trusted aides that Marty appointed were under attack from the get-go. His counsel Hillary Perkins was accused of being inadequately pro-life (this was defamatory) and run out after two days on the job. Dr. Tracy Beth Høeg, MD, PhD, an epidemiologist who saw the truth during COVID and said so, was criticized most of her tenure until being fired in a perp-walk kinda way last week, with no reason given.

The job is hard enough when the administration has your back, but when they’re never satisfied with you or your people, it makes it very difficult to persevere in doing good. I will also note that this administration has a particularly obnoxious pattern of putting tons of effort and agony into getting people through Senate confirmation, and then driving out these Senate confirmed people within a year. There is something that feels inappropriate about this waste of Senate time (that the Senate could be using to fix health care), though of course, they’re perfectly good at wasting their own time:

That said, to be honest, no matter how many competent staffers, no matter who is president, the Commissioner job is impossible for anyone. Even if a Commissioner were totally committed to rubber-stamping industry wish-lists and pom-pomming the status quo, that too would create massive headwinds from a variety of anti-status-quo quarters (though not as powerful). Those headwinds obviously become Category-5 for someone who wants to actually drive reform.

Nobody who comes into this job has ever run anything as life-or-death important, complex, politically charged, and many-mastered as the FDA. The agency regulates a fifth of the economy, including, as I mentioned above, some of the most powerful industries on earth: Big Pharma, Big Food, Big Tobacco. Pharma alone employs almost three lobbyists per member of Congress, and believe me, those lobbyists make life a living hell for any Commissioner.

A CEO who runs in elite, business-leader circles, recently recounted for me a conversation with two pharma and biotech executives, a couple months ago. They were bragging that “our cabal is planning to eliminate Makary. We have a plan and we will replace him, Bobby (Secretary Kennedy), and their deputies with our people.”

It’s clear the plan is executing on schedule.

Just peruse the almost dozen op-eds in the Wall Street Journal since last Fall, haranguing Marty for not approving a drug by Replimune that has unreliable data coming out of its flawed trials - you can see the strategy at work (three independent scientific teams at the FDA recommended against approval. Marty defended the scientists). Scan the political trade press daily and you’ll see chatter about the constant whining from the industry to the White House office established to placate aggrieved donors. Or the disgruntled former FDA employees serving as sources for every media hit, even though what they perceived as draconian DOGE layoffs happened before Marty took office. The rare-disease patient groups, being told by Pharma about how the FDA is delaying their new wonder-drug that could cure Huntington’s disease (even though the actual study methodology was at best controversial), ginned up anti-FDA grievance on social media and to the White House office established to placate aggrieved stakeholder groups (yes, there’s a relationship-babysitter WH office for everything).

Now, if you ask some insiders - even some of the non-corrupt ones - the story that you might hear is that Marty was partly to blame for his own downfall. All I can say is that when someone pushes the envelope and doesn’t trust the people who have presided over the status quo, they often look like the problem instead of the solution.

I wasn’t in the meetings. I couldn’t have witnessed anything that took place at FDA, HHS or at the White House between Marty and anyone else. So I can’t know the exact facts.

But I have checked in with Marty pretty regularly during his year and a half journey, and over that time, watched him go from sounding enthusiastic and hopeful during the pre-confirmation process to frustrated and disappointed by government corruption. The let-down has been palpable over not being able to fully reverse the agency capture and put the public back in public health.

I know that people who know us both are saying I only see the best side of Marty. That’s true - I do. But I’ve loved him like a brother since we were both bright-eyed kids and it has pained me to watch the dream for Making America Healthy Again that we both shared for so long cut brutally short.

Still, FDA under Marty’s leadership managed to eek out important reforms that we can all celebrate. Here are some of my favorites:

• Took the black box warning off of menopausal hormone therapy

• Removed artificial dyes from food

• Flipped the Food Pyramid to promote real food rather than processed crap at the base of the old pyramid.

• Cracked down on misleading Big Pharma advertising

• Reduced cruel animal testing

• Implemented surprise inspections of manufacturing facilities (rather than pre-announced, pre-warned and therefore useless scheduled inspections)

• First real-time clinical trial where regulators watch data signals in the cloud rather than waiting years for researchers to report results

• Made drug rejection letters public

No matter how you hear Marty’s record characterized, who likes him or who hates him, never forget this: the industries that FDA regulates are not your friends.

They do not profit from you being healthy. They have long, scandalous histories of knowingly peddling deadly products, rather than coming clean for the sake of patient safety. They have paid tens of billions in enforcement penalties for fraud, cover-ups and other violations. They will spend and are spending more money than God to thwart FDA’s scrutiny and oversight and any effort to reform their ways.

As their market share and bottom lines have grown to almost $2 trillion over the past century, FDA has presided over the American people becoming sicker, fatter, sadder, more infertile, more addicted - but more medicated - than we’ve ever been in our country’s history. The agency’s long decades of regulatory capture have contributed to our extinction-level chronic disease crisis.

The FDA exists to protect the American public from the depravity and corruption of the regulated industries, not to protect them from public scrutiny or accountability, or to cheerlead their products.

That’s why we have to continue to demand that the FDA take your side over corporations - everyday and always. Leaders who try to do this will get painted by the industry and its allies as radicals, cowboys and assholes. It’s a kamakazi suicide mission that you’d have to be crazy even to consider. But what choice do we have but to keep trying to recruit them and support them in office?

None of us is perfect, and no one has ever been truly prepared to take on this mother-of-all-jobs as FDA Commissioner. But win or lose, my brother-in-arms Marty has always been on your side.

I know he’ll continue to fight for you in his future endeavors.

PS: It’s muh-CARE-ee, not MACK-uh-ree or muh-KAH-ree. You’re welcome.